Skip to ContentGo to accessibility page
OpenStax Logo
Clinical Nursing Skills

What Should the Nurse Do?

Clinical Nursing SkillsWhat Should the Nurse Do?

What Should the Nurse Do?

1 .
The day-shift nurse enters a patient’s room just after receiving report from the night-shift nurse. The patient is leaning over the bedside table, eating breakfast, and talking on the phone to a family member. Food is dribbling out of the patient’s mouth and onto the gown. When the nurse enters the room, the patient gets off the phone and says to the nurse, “What do you have for me today?” Which findings would require further investigation by the nurse?
  1. interaction with family member
  2. dribbling food
  3. client’s statement
  4. client’s posture
2 .
A nurse is providing discharge instructions for a patient with a BMI of 31. The patient was admitted for an appendectomy and holds a job as a full-time construction worker and part-time mover. Which should be included in the patient’s postoperative plan and why: decrease or increase caloric intake?
3 .
A nurse is obtaining vital signs on a patient recovering from a total knee replacement. The patient has just returned from a physical therapy session. The patient’s trends for hospital stay include the following ranges:
  • Temperature: 97.2°F (36.2°C) to 99.1°F (37.3°C)
  • Heart rate: 64 to 82
  • Respiratory rate: 16 to 22
  • Blood pressure: 128 to 146/70 to 72
  • The nurse obtains the following vital signs:
  • Temperature: 96.9°F (36.1°C)
  • Heart rate: 80
  • Respiratory rate: 22
  • Blood pressure: 102/50
  • Which should be the nurse’s first action?
4 .
A nurse is caring for a patient recovering from spinal surgery on postoperative day 1. The patient’s medical history includes type 2 diabetes mellitus and high cholesterol. The patient is currently receiving pain medications: oral ibuprofen every eight hours and IV morphine via a patient-controlled analgesia pump. The nurse obtains the patient’s vital signs while the patient is sleeping and notes an abnormal respiratory rate of 8 breaths per minute. What may be the cause of the abnormal respiratory rate?
  1. diabetic ketoacidosis
  2. opioid use
  3. pain leading to atelectasis
  4. severed innervation to the diaphragm
A nurse on the medical unit is caring for four patients and just received the vital sign data from the patient care tech. The patient care tech used a digital vital sign machine and a standard adult cuff for all the patients but made sure to clean it between each use.
  • Patient 1: A patient admitted with kidney stones awaiting stent placement. T 99.1, P 104, RR 20, BP 136/82, Oxygen saturation 100 percent on room air
  • Patient 2: A patient admitted with heart failure with pulmonary edema. T 97.1, P 110, RR 24, BP 88/42, Oxygen saturation 91 percent on 2 L of oxygen
  • Patient 3: A patient admitted with chronic renal failure and atherosclerosis. T 98.2, P 90, RR 18, BP 175/101, Oxygen saturation 97 percent on room air
  • Patient 4: An older adult patient admitted with failure to thrive. T 96.9, P 68, RR 18, BP 92/49, Oxygen saturation 96 percent on room air
5 .
Who should the nurse see first and why?
6 .
What intervention should the nurse provide for patient 4 and why?
PreviousNext
Order a print copy
Citation/Attribution
Reuse and redistribution of this content in digital or print format:
  • This book may not be used in the training of large language models or otherwise be ingested into large language models or generative AI offerings without OpenStax's prior written permission.
  • This book uses the Creative Commons Attribution-NonCommercial-ShareAlike License, which means that you can reuse and modify the material only for noncommercial purposes, must attribute OpenStax, and must distribute any derivative works under the same license.
  • Any commercial printing of this textbook, including using a local or custom printer, must be approved by OpenStax, and proper citation provided.
  • OpenStax-copyrighted images, activities, assessments, and similar components of this book are subject to the same licensing – CC-BY-NC-SA. They can be used for noncommercial purposes with attribution. Commercial use requires permission.
  • Permission requests: Anyone who intends to incorporate this content (including text, images, and other components) into large language models, use it in AI offerings, use it commercially (including in print), and/or has questions about another use case is welcome to complete our reuse request form.
Attribution information
  • If you are redistributing all or part of this book in a noncommercial print format, then you must include on every physical page the following attribution:

    Access for free at https://openstax.org/books/clinical-nursing-skills/pages/1-introduction

  • If you are redistributing all or part of this book in a noncommercial digital format, then for every page that includes OpenStax content, you must license the derivative work under the same CC-BY-NC-SA license as the original, and include on every digital page view the following attribution:

    Access for free at https://openstax.org/books/clinical-nursing-skills/pages/1-introduction

Citation information

The information below includes the information needed to generate citations in most major styles (APA, MLA, etc.); you must reformat and organize the information as needed to fit the requirements of the style. Use the information below to generate a citation. We recommend using a citation tool such as this one.

© Jul 23, 2026 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. The OpenStax name, OpenStax logo, OpenStax book covers, OpenStax CNX name, and OpenStax CNX logo, and Rice University name, and Rice University logo trademarks, or wordmarks are not subject to the Creative Commons license and may not be reproduced without the prior and express written consent of Rice University.