A nurse is caring for a school-age child who has leukemia.

Exhibits

Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.

A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?

A nurse is providing teaching to a client who has atrial fibrillation and reports dizziness and palpitations. Which of the following should the nurse understand is the cause of these manifestations?

A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client’s most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client?

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

A nurse on a cardiac care unit is caring for a preschooler.

Hospital Day 1, 17:38:

Medication Administration Record.

20:15:

Received 4-year-old child with an exacerbation of heart failure.

Family reports history of congenital mitral stenosis.

Breath sounds with wheezing noted in bilateral lower lobes.

Nonproductive cough noted.

Dyspnea with respiratory rate 30/min.

Oxygen at 2 L/min applied per nasal cannula.

Telemetry applied:

Sinus rhythm at rate 116/min.

Abdomen soft, nontender.

Bowel sounds positive in all 4 quadrants.

Lower extremities with 2+ edema noted.

Pedal pulses palpable bilaterally.

Peripheral saline lock intact to right forearm with no signs and symptoms of infection.

Weight 26 kg (44 lb).

Increase in dyspnea noted with orthopnea.

Nasal flaring with respiratory rate of 36/min. Lung sounds with wheezing noted throughout.

Lower extremity edema 3+ to bilateral lower extremities.

Extremities cool with decreased skin pigmentation noted.

Peripheral pulses weak bilaterally.

Jugular vein distention noted.

Provider notified.

Received prescription for additional dose of furosemide.

The client is at risk for developing:

A nurse is caring for a client.

Nurses Notes: Day 1: Custom Nursing Assessment.

Vital Signs: Diagnostic Results: Client is admitted with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.

Prepare to administer an antibiotic to the client.

Which of the following actions should the nurse take? (Select all that apply.)

A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hours. Which of the following categories of shock should the nurse recognize is occurring?

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, “I can feel the congestion in my lungs, and I certainly cough a lot, but I can’t seem to bring anything up.”. Which of the following actions should the nurse take to help this client?

A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.

The nurse is caring for the client following a thoracentesis.

(Select the 3 findings that require immediate follow-up.)

A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?