Exhibits

Nursing actions: Indicated/contraindicated/non-urgent

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

The nurse is developing the plan of care for a client with pneumonia and includes the nursing problem of Ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important for the nurse to include in the client's plan of care?

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

Patient Data

The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

The nurse is caring for the client.

Which of the following assessment findings should the nurse prioritize?

Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

Click to highlight the statement(s) made by the client that indicate she understood the treatment recommendations and is developing an understanding of her disease. Select all that apply.
1.    Working with an addiction therapist for several months will assist in my recovery.

2.    The Alcoholics Anonymous program would be a great resource, but they do not have meetings when I'm free.
3.    It is not safe for me to drink alcohol, but I am still able to smoke marijuana without problems.
4.    Identifying potential triggers allows me to proactively utilize coping strategies.

5.    Relapse is an expected complication of substance use; thus, prevention strategies and awareness of my emotions are important.
6.    The treatment options for alcoholism are limited to inpatients, with very few resources for outpatients.
 

The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take?

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?