During wound care, the nurse observes a sudden increase in yellow drainage. What should the nurse do first?
Documenting the drainage and notifying the provider helps evaluate for potential infection or wound complications.
A client with anxiety is breathing rapidly and complaining of tingling in their fingers. What should the nurse do first?
Tingling and rapid breathing may indicate hyperventilation. Encouraging slow breathing helps restore COu2082 balance.
The nurse is caring for a client with suspected dehydration. Which assessment is most important?
Monitoring urine output helps determine kidney perfusion and hydration status.
A client receiving IV antibiotics complains of sudden itching and flushing. What should the nurse do first?
Itching and flushing may indicate an allergic reaction. Stopping the infusion prevents additional exposure.
A client taking furosemide reports dizziness when getting out of bed. What is the nurseu2019s best initial response?
Diuretics can cause orthostatic hypotension. Teaching the client to stand up slowly helps prevent falls.
The nurse is caring for a client with a new colostomy. The client asks what a healthy stoma should look like. What is the best response?
A healthy stoma should appear moist and pink to red, indicating adequate blood supply.
A client with diabetes reports new numbness in their feet. What is the nurseu2019s best action?
Numbness may indicate diabetic neuropathy and requires provider notification for monitoring and management.
A client on opioid pain medication reports constipation. What should the nurse recommend?
Opioids slow gastrointestinal motility. Increasing fiber and fluid intake helps relieve constipation.
The nurse notices a client with pneumonia has an increased respiratory rate and difficulty speaking full sentences. What should the nurse do first?
Difficulty speaking in full sentences can indicate respiratory distress. Assessing oxygen saturation helps determine the severity and need for rapid intervention.