Exhibits

Drag from the options to complete the sentence

After listening to the client's symptoms, the nurse realizes that she likely has

related to

Options for 1

(separation anxiety, acute stress disorder, phobia, hallucinations)

Options for 2

(undiagnosed mental health disorder, traumatic stress exposure, side effects of medication, overstimulation)

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg.

Which assessment finding warrants the most immediate intervention by the nurse?

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important?

A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care?

An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement?

The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.

For each client statement, click to highlight the statement(s) below that require follow up teaching by the nurse.

•  I am at high risk for post-traumatic-stress disorder because I have acute stress disorder
•  I can use holistic approaches like meditation to help my symptoms.
•  I can learn to manage my thoughts better through therapy.
• Many people have the same response to a stressful situation as I am having.
•  This diagnosis means that I am crazy.
•  I will probably need to be on medication for the rest of my life.

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. Which action should the nurse implement?

A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL (109 g/L), hematocrit 29% (0.29), hepatitis surface antigen positive, group B Streptococcus positive, and rubella non- immune.

Which intervention should the nurse implement?

Reference Range

• Hemaglobin [Reference Range:12-16 g/dL (120-160 g/L)]
• Hematrocrit [Reference Range:Pregnant female: 37% to 47% (0.37 to 0.47 volume fraction)] Hepatitis Surface Antigen [Reference Range: negative]
• Group B Streptococcus [Reference Range: negative]

An infant who weighs 22 pounds receives a prescription for amoxicillin 20 mg/kg/day by mouth in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with each dose? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)

The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?