Patient Data

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 findings

Neurological Alert and oriented times 4.

Cardiovascular WNL.

Respiratory WNL.

Gastrointestinal/Genitourinary Voided twice throughout night, urine clear amber in appearance. Reports no dysuria. No bowel movement but the client is passing gas.

Integumentary 4 abdominal incisions from laparoscopic procedure sealed with surgical glue. No drainage, redness, or edema present.

Musculoskeletal Reported chronic knee pain. 5+ strength in bilateral upper extremities, 5+ strength in bilateral lower extremities.

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

A client has received a prescription for a fluid bolus of 0.9% sodium chloride, 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver? (Please enter the numerical value only.)

The question is asking for the rate at which the infusion pump should be programmed to deliver a fluid bolus of 200 mL in 30 minutes. This can be calculated using the formula for rate which is volume divided by time.

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?

A client who has borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by claiming the night nurse is aloof and expresses joy to see that, "My favorite nurse is on duty now." Which response is best for the nurse to provide to this client's dichotomous tendency?

A client arrives for an annual physical exam and reports having calf pain. The client's health history includes peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms?

An older adult client with a history of heart failure is admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Patient Data

Review H and P and laboratory results.

What item(s) should be included in the treatment regimen for this client? Select all that apply.

The nurse is caring for a client with a history of type 2 diabetes mellitus and hypertension who arrives at the clinic for a scheduled visit. Which finding requires further follow-up by the nurse?
Creatinine: Female: [0.5 to 1.1 mg/dL (44 to 97 µmol/L)], Male: [0.6 to 1.2 mg/dL (53 to 106 µmol/L)]

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?