Patient Data

Exhibits

Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

The nurse working in a critical care unit (CCU) is assigned the care of two clients, one with pneumonia who is being mechanically ventilated, and the other who had a thoracotomy yesterday and is reporting incisional pain. Which action(s) should the nurse perform first?

Patient Data

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.

Patient Data

The nurse needs to determine the priority assessment before administering morphine.

Select  from Word Choices to complete the sentence.

Before administering morphine, the most important assessment to perform is to check the client's ______________

The nurse is caring for a client with anorexia nervosa who states, "I feel powerless when I gain weight." Which problem should the nurse identify as a priority?

A 4-month-old with hydrocephalus is admitted to the hospital for shunt revision. When assessing for increased intracranial pressure, the nurse should observe the child for which finding(s)? Select all that apply.

A client with Parkinson's disease receives a prescription for benztropine. Which common adverse effect(s) should the nurse include in the teaching plan? Select all that apply

A client who is obese reports severe pain and inability to bear weight in the right knee after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?

A client who experiences recurrent episodes of depression tells the nurse of a desire to discontinue the prescribed antidepressant. The client describes feeling less depressed after taking the medication for the past couple of weeks and the client does not like the side effects of the medication. Which response is best for the nurse to provide?

The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.)

Patient Data

Review H and P and nurse's notes.

Click to highlight which assessment finding(s) should the nurse attend to right away?

Admitted client.

Vital signs

Temperature: 96.9° F (36.1° C) internal probe via urinary catheter

Heart rate: 128 beats/minute, sinus tachycardia (ST)

Respirations: 14 breaths/minute

Patient Data

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg

Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2)

The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a PIV line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members. The client opens her eyes to verbal stimuli and follows verbal commands.