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.

Select from statement options to complete the sentence.

To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client's

The nurse uses the Modified Caregiver Strain Index (MCIS) and determines that the daughter is under significant stress caused by the assumption of her mother's care. The nurse is planning to have a discussion with the daughter on decreasing the stress she is experiencing as a caregiver.

Select the 3 statements that the nurse should include when discussing caregiver stress with the client's daughter.

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

The client who has emphysema and recently experienced a stroke receives a prescription for a metered-dose inhaler with a spacer device. The client asks the nurse if using the spacer is necessary. Which information should the nurse provide?

Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions.

Drag from the Word Choices to complete the sentence.

The client demonstrates effective epidural anesthesia by

Review H and P and nurses’ notes.

Click to highlight which assessment findings should the nurse attend to right away?

Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous 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.

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.