A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury.

Exhibits

Select 1 condition and 1 client finding to fill in each blank in the following sentence.</p>

The client is at risk for developing

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due to

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.

The nurse is assessing the adolescent 4 hr following fasciotomy. Highlight the findings below that indicate the adolescent's condition is improving.

Admission Assessment

1400:

Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.

Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Nurses' Notes 2300:

Adolescent is drowsy and reports nausea. Respirations shallow. Lungs clear. Unproductive cough present. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with hypoactive bowel sounds in all four quadrants. Right lower extremity fasciotomy, dressing clean, dry, and intact. Extremity pulse +3. Capillary refill 2 seconds. Right extremity is warm to the touch. Adolescent reports no numbness or tingling. Adolescent reports pain as 2 on a scale of 0 to 10.

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take?

A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes

1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the 6 actions the nurse should take.

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury.

Select 1 condition and 1 client finding to fill in each blank in the following sentence.</p>

The client is at risk for developing

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?

A nurse is reviewing the medical record of a client. These are the medical reports; Hypoactive bowel sounds upon auscultation, abdomen soft, not distended on palpation and urinary output of 130mL/4hr. Which of the following findings should the nurse report to the provider?