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, A nurse is assisting with the care for a client on a medical surgical
unit. Exhibit 1
Nurses' Notes
1000:Client admitted to unit from the emergency department for a right hip fracture
following a fall. Leg is currently splinted and client is scheduled for surgery at
1400.1100:Provider met with client to review informed consent.
When taking actions, the nurse should notify the nurse manager of the problem, followed
by completing a facility incident report. When ethical or potential legal occurrences
occur, the nurse should report the occurrence to their nurse manager, facility
administrator, or a risk manager. The nurse should follow facility guidelines in
completing the incident report.
A nurse is assisting in the care of a client.
Exhibit 1
Exhibit 2
Exhibit 3
Nurses' NotesDay 1, 0915:Client presents to ED with reports of headache with sensitivity to
light that started yesterday. Client states, "I have had muscle aches too." The client is alert
and oriented to person, place, and time. Lung sounds are clear to auscultation bilaterally.
S1, S2 auscultated no murmur detected. Rates pain as a 5 on a pain scale of 0 to 10.
Obtained labs and sent.Day 1, 1045:Nurse enters client's room. Client states "My head is
killing me and my neck is stiff and hurts too!" Client is diaphoretic. Client is confused at
times, states "I need to go in the kitchen and get something to drink." Client rates pain as a 8
on a pain scale of 0 to 10. Pain medication given as prescribed. Provider notified.
When using the urgent versus non-urgent plan of care to prioritize hypothesis for the
client care, the PN should collaborate with charge nurse and recommend addressing the
client's WBC count, orientation status temperature, respiratory rate, and pain rate. The
client's WBC count and temperature are above the expected reference range and could
indicate infection. The client orientation status has changed, which requires further
evaluation. The client's pain rate has increased, which requires prompt intervention by
the nurse. The client's respiratory rate has also increased, which requires further
evaluation by the nurse.