In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?

Reference Range:

Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)]

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea.

Vital Signs

Heart Rate-beats/minute- 110 Respirations - breathes/minute- 28 Blood Pressure – mmHG- 80/60

Arterial blood gases (ABGs)

Ph- 7.34

PaCO2- 34 mmHg

HCO3- 20 mmol/L

pO2- 90 mmHg

Electrolytes Results

Sodium

130 mEq/L(mmol/L) Potassium

2.5 mEq/L (mmol/L) Chloride

95 mEq/L (mmol/L)

Reference Range:

Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Chloride [98 to 106 mEq/L (98 to 106 mmol/L)]

PaCO2 [35 to 45 mm Hg]

HCO, [21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg)

The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.)

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

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]

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?

Reference Range:

Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

A client receives a prescription for a fluid bolus of 0.9% sodium chloride, USP 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver?

(Enter numerical value only.)

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.

Exhibits

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"

"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."