Exhibits

Which interventions are indicated to promote positive outcomes for the client? Select all that apply.

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

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

The nurse reviews the client data. What discharge education should the nurse provide? Select all that apply.

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula, is currently short of breath. Which action should the nurse take?

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?

A client who experiences recurrent episodes of depression tells the nurse of a desire to discontinue the prescribed antidepressant. The client describes feeling less depressed after taking the medication for the past couple of weeks and the client does not like the side effects of the medication. Which response is best for the nurse to provide?

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?

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?

Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization.

What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

The nurse is assessing an older adult client who is having difficulty remembering events from earlier in the day and concentrating on the questions being asked. A family member shares that the client's home was recently sold and the client has just moved in with them. Which nursing response best promotes effective communication with the family?