Patient Data

Exhibits

Select the 4 assessment findings that require immediate follow up.

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.

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

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

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal.

Which action should the nurse implement?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

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.

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?