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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.

A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider?

These are the medical report: Abdomen soft, no palpable mass, bowel sounds heard. 

Temperature 97.7°F, Urine specific gravity 1.035, albumin 4.5 mg/L, prealbumin 25 mg/dL and potassium 4.2 mg/dL

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

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?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices increased levels of Anti-Glycan Neu5Gc Antibodies (AGNA). Which changes should the PN anticipate to be included in the client's plan of care?

A nurse is assessing a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect?

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.

Nurses' Notes

0600:

Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management.

0615:

Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered.

Which of the following interventions should the nurse implement?

Select all that apply.

A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy.

Vital Signs

1100:

Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min

Blood pressure 128/68 mm Hg

Pulse oximetry 97% on room air

1115:

Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min

Blood pressure 138/74 mm Hg

Pulse oximetry 95% on room air

1130:

Temperature 38.6° C (101.5° F). Heart rate 136/min

Respiratory rate 16/min

Blood pressure 154/86 mm Hg

Pulse oximetry 95% on 2 L/min via nasal cannula

Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm.

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?