A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

Patient Profile:

• Age: 68 years
• Gender: Male
• Medical History: Hypertension, Type 2 Diabetes Mellitus, Atrial Fibrillation
• Medication History: Lisinopril, Metformin, Apixaban

Presenting Complaint:

• The patient was admitted to the hospital with shortness of breath, fatigue, and swelling in his legs. He reported a weight gain of 5 pounds over the past week.

Vital Signs on Admission:

• Blood Pressure: 160/95 mmHg
• Heart Rate: 110 bpm (tachycardia)
• Respiratory Rate: 24 breaths/min (tachypnea)
• Temperature: 98.6°F (37°C)
• Oxygen Saturation: 86% on room air

Physical Examination:

• General: Appears anxious and fatigued.
• Cardiovascular: Irregular heart rhythm
• Respiratory: Diminished breath sounds, crackles in lung bases bilaterally
• Abdomen: Soft, non-tender, no distension
• Extremities: Bilateral pitting edema (2+)

Diagnostic Tests:

1. Echocardiogram: Confirmed reduced ejection fraction (EF of 35%)
2. Chest X-ray: Showed cardiomegaly and bilateral pleural effusions
3. Electrocardiogram (ECG): Atrial fibrillation noted
4. B-type Natriuretic Peptide (BNP): 800 pg/mL
5. Arterial Blood Gas (ABG): pH 7.35, PaCO₂ 45 mmHg

Which of the following prescribed interventions would the nurse complete first?

Patient Profile:

• Name: Mr. John Smith
• Age: 68 years
• Medical History: Osteoarthritis of the hip, Type 2 diabetes, hypertension, and atrial fibrillation
• Current Medications: Lisinopril, Metformin, Warfarin
• Surgical Procedure: Total hip replacement (THR) due to severe pain and limited mobility.

Preoperative Care:

• The nurse conducts a comprehensive assessment, including a physical examination, vital signs, and a review of Mr. Smith's medical history.
• Preoperative labs are ordered with the following abnormal values noted:
  • Complete Blood Count (CBC):
    1. Hemoglobin: 12.0 g/dL (normal range: 13.5-17.5 g/dL)
    2. Hematocrit: 36% (normal range: 38.8-50%)
  • Basic Metabolic Panel (BMP):
    1. Serum Creatinine: 3 mg/dL (normal range: 0.6-1.2 mg/dL)
    2. Blood Urea Nitrogen (BUN): 24 mg/dL (normal range: 7-20 mg/dL)

• • Coagulation Studies:
    1. INR: 5 (normal range: 0.8-1.1)

Intraoperative Care:

• The scrub nurse assists in positioning Mr. Smith on the operating table.

Which pre-op abnormal lab value would be the most concerning?

Patient Profile:

• Name: Sarah Johnson
• Age: 54
• Diagnosis: Metastatic breast cancer, Stage IV, diagnosed six months ago with metastasis to the liver and bone

Treatment Plan:

• Surgery: Lumpectomy with axillary lymph node dissection
• Chemotherapy: Adriamycin and Cyclophosphamide (AC) regimen
• Radiation Therapy: Targeted treatment to the chest wall post-surgery

Clinical Presentation:

Subjective Data:

• Reports of nausea and vomiting, especially after chemotherapy sessions
• Expresses feelings of sadness and fear regarding her prognosis and the impact on her family
• States she has lost 10 pounds in the last month due to decreased appetite and nausea
• Describes pain in the surgical area and generalized body pain that worsens at night
• Mentions experiencing a red, itchy rash on her chest from radiation therapy

Objective Data:

• Vital signs: HR 78 bpm, BP 120/80 mmHg, Temp 98.6°F
• Weight: 135 lbs (down from 145 lbs)
• Physical examination reveals tenderness in the left breast and axilla, and a rash in the radiation field
• Labs: Mild anemia (Hgb 10.5 g/dL), elevated liver enzymes

Nursing Diagnoses:

1. Nausea related to chemotherapy as evidenced by patient report and vomiting episodes
2. Imbalanced Nutrition: Less than Body Requirements related to nausea and weight loss as evidenced by a 10-pound weight loss and decreased appetite
3. Acute Pain related to surgical procedure and cancer

What intervention can the nurse implement to help manage Sarah's nausea?

Patient Profile:

• Age: 68 years
• Gender: Male
• Medical History: Hypertension, Type 2 Diabetes Mellitus
• Medications: Lisinopril, Metformin
• Allergies: None

Chief Complaint: The patient presents to the emergency department (ED) with sudden onset of right-sided weakness and difficulty speaking that began approximately 1 hour prior to arrival.

Choose three parameters the nurse should monitor to assess the patient's progress.