A nurse on a medical unit is admitting a client.

Exhibits

Click to highlight the findings that should be reported to the provider. To deselect a finding, click on the finding again.

Nurses' Notes

Day 1, 1600:

Client admitted from provider's clinic reporting shortness of breath, dry hacking cough, dizziness, and "heart racing."

States they are not able to sleep well on their back at night because of difficulty breathing.

Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 130/min, ECG monitor showing sinus tachycardia, S1, auscultated. Lower extremity edema noted, 2+ bilaterally, Radial and pedal pulses 1+ bilaterally.

Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.

Client reports gaining 10 pounds in the past month.

Reports history of type 2 diabetes mellitus and hypertension.

The nurse is preparing the client for discharge.

For each potential discharge instruction, click to specify if the potential prescription is anticipated or contraindicated for the client.

A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?

A nurse is assisting in the care of a client who is experiencing a postpartum hemorrhage.
Which of the following medications should the nurse plan to administer?

A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving IV fluids. The nurse realizes that the incorrect IV solution is infusing. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory results indicates a possible complication of this therapy?

A nurse is preparing to administer cefacior to a preschooler who weighs 20 kg. The child is to receive cefacior 30 mg/kg/day to divide equally every 8 hr. Available is cefaclor suspension 125 mg/5 mL. How many mL should the nurse administer for one dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is assisting with planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding effectively?

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first?