An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first? A. Explore client's readiness to discuss the situation B. Determine the frequency and type of client's abuse C. Report the finding to the police department D. Discuss treatment options for abusive partners – A client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care? A. Maintain accurate intake and output B. Administer prescribed diuretic C. Weigh client every morning D. Restrict daily fluid intake to 1500mL - The nurse is evaluating the chest drainage system of a client with a chest tube inserted to treat a left hemothorax. Which finding requires intervention by the nurse? A. Rise and fall of water level with respiration B. Continuous bubbling in the water-seal chamber C. Total fluid level in water-seal chamber unchanged D. An average collection of 50 mL/hr drainage – A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48 hours. Based on these findings, it is most important for the nurse to review the laboratory value for which medication? A. Lorazepam B. Fluoxetine C. Divalproex D. Olanzapine A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response? - answerB. Normal electroencephalogram after drug administration The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely