Patient Data

Exhibits

The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.

What interdisciplinary team member(s) should assist the client in recovery? Select all that apply.

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions?

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

The nurse is caring for the client.

Which of the following assessment findings should the nurse prioritize?

What 2 orders should the nurse complete first?

An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

Patient Data

Click to select the 5 most important nursing interventions for postoperative client care.

The nurse of a medical-surgical unit receives a report from a postanesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an IV infusion of 1,000 mL lactated Ringer's infusing at 125 mL/hr into the left wrist with 300 mL remaining. Prescriptions include morphine sulfate 2 mg IV every 2 to 4 hours for pain, last administered 30 minutes ago; ondansetron 4 mg IV every 8 hours for nausea, last administered 15 minutes ago." Which additional information is most important for the nurse to obtain in the report?