Exhibits

Click to highlight the findings that indicate the client is stable for discharge.

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning.

She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment

Neurological Alert and oriented times 4. Cardiovascular WNL

Respiratory WNL

Gastrointestinal/Genitourinary Voided twice throughout night

A client is being discharged home after being treated for heart failure (HF. Which instruction should the nurse include in this client's discharge teaching plan?

An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal, "Increase daily intake of fluids." Which nursing intervention is most useful in assisting the resident to meet this goal?

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD?

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA. The client's parent is insisting to know the laboratory test results. Which is the best response for the nurse to provide?

One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs include oral temperature 99° F (37.2° C, heart rate 110 beats/minute, respiratory rate 30 breaths/minute, and blood pressure 160/90 mm Hg. The client's skin is pale, and the surgical dressing is dry and intact. Which intervention is most important for the nurse to implement?

The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

Which needle should the nurse use to administer IV fluids via a client's implanted port?

On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for family. Which information is most important for the nurse to obtain?

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. After obtaining vital signs, the nurse should implement which intervention?

While removing staples from a client's postoperative wound site, the nurse observes that the client's eyes are closed and the client's face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, which action should the nurse implement?