A nurse is caring for a client in the emergency department.

Exhibits

For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.
Assessment Findings: DKA /HHS

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

A nurse is caring for a client who has cervical cancer and is receiving brachytherapy.

Which of the following actions should the nurse take?

A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessment should be the nurse's priority?

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a client who had a bilateral orchiectomy.
The nurse should instruct the client to expect which of the following symptoms?

A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?

The nurse is reviewing the client's medical record.

The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved?
Select all that apply.

A nurse is admitting a client who reports tightness in their chest that radiates to left arm.

Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Nurses' Notes

1000:

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.