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.

A nurse is caring for a client with binge eating disorder. Which goal should the nurse establish first with the client?

The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include a sodium of 129 mEq/L (129 mmol/L), a glucose of 54 mg/dL (2.97 mmol/L), and a potassium of 5.3 mEq/L (5.3 mmol/L). When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication?
Reference Range:
Sodium [136 to 145 mEq/L (136 to 145 mmol/L)],
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)],
Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Patient Data

What can the nurse do to help the parents decrease their anxiety? Select all that apply.

A client experiencing recurrent episodes of depression expresses a desire to discontinue the prescribed antidepressant medication. The client reports feeling less depressed after taking the medication for the past few weeks but dislikes the side effects. What is the best response for the nurse to provide?

Patient Data

Review H and P, nurse's note, and laboratory results.

What other nutritional recommendation(s) would be helpful for this client in reducing risk for type 2 diabetes mellitus? Select all that apply.

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?

A client who weighs 110 lbs has received a prescription for dalteparin, 150 units/kg to be administered subcutaneously daily for 4 months. The medication is available in a 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Please enter the numerical value only.)

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?