Patient Data

Exhibits

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According to the laboratory values, the client has

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; related to

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, or

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.

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?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider (HCР)?

A client who was discharged 3 days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen left lower leg. The nurse is preparing to initiate heparin therapy. Which additional intervention should the nurse include in this client's plan of care?

The nurse is evaluating the client’s response to pain management.

Click to highlight the findings that indicate the client is experiencing the therapeutic effects of the medication.

Pain level presently 3 on a 0 to 10 scale. The client reports feeling "sleepy." Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer. New mild cough noted. Repositions in bed with minimal assistance. Attempted to get up to the chair, but experienced dizziness with standing.

Which finding should the nurse recognize as a potential complication in a client with hypertension?

Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

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.

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding?

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?