Patient Data

Exhibits

Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Click to highlight the findings that would indicate the client is progressing and ready for an epidural.

0245

Peripheral IV (PIV) started in left hand with 20 gauge catheter. Lab specimens drawn. IV fluids of lactated Ringer's started Infusing at 75 mL/hour. Contractions are now every 4 minutes lasting 45 seconds. Mother says they are getting more painful. Instructed her and husband on slow breathing and relaxation techniques. Husband will assist wife breathing. Client instructed she can have IV pain medication if she needs it until time for epidural.

0330

Contractions are now every 3 to 4 minutes apart and client reports they are really hurting. Asking for epidural. Healthcare provider (HCP) to bedside. SVE reveals 5 cm dilated, 90% effaced and 0 station. Performed artificial rupture of membranes with clear amniotic fluid.

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.

Which intervention is most important for the nurse to include in the plan of care?

Which client should the charge nurse on the oncology unit assign to a registered nurse (RN), rather than a practical nurse (PN)?

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes which pathology as the cause of the symptoms?

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include a heart rate of 122 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 170/90 mm Hg. Which assessment finding warrants the most immediate intervention by the nurse?

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

The client has recovered from surgery and is ready to be discharged.

Highlight findings that indicate the client is stable and ready to be discharged.

The client returned from appendectomy surgery last night at approximately 2100. The client was admitted for observation due to a delay in waking from anesthesia. The client is currently resting in bed. The incision dressing is dry and intact, and no bleeding is noted. The client tolerated clear liquids post recovery and has advanced to a soft diet. The client ambulated around the unit this morning and tolerated activity well. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus. Pain is tolerated with analgesia PO.

Following a gunshot wound, an adult client has a hemoglobin level of 4 g/dL (40 g/L). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement?

Reference Range

• Hemoglobin [14 to 18 g/dL (140 to 180 g/L)