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 setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The nurse manager is involved in agency restructuring. During this reengineering process, it is most important for the nurse to address which employee concern?

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?

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?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

While the nurse is preparing a scheduled IV medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

On the second postoperative day, a client who had a colon resection is starting to eat and ambulate with assistance. Although the client has a prescription for an oral analgesic, they request that the PCA containing morphine be continued for one more day due to fear of pain. Which intervention is most important for the nurse to implement?

Patient Data

The nurse educates the parents on post discharge care for the child.

What should the nurse include in post discharge care education? Select all that apply.

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 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?