Patient Data

Exhibits

The nurse reviews the client data.

What discharge education should the nurse provide? Select all that apply.

Patient Data

Click to highlight the findings that indicate the client is stable for discharge.

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment findings

Neurological Alert and oriented times 4.

Cardiovascular WNL.

Respiratory WNL.

Gastrointestinal/Genitourinary Voided twice throughout night, urine clear amber in appearance. Reports no dysuria. No bowel movement but the client is passing gas.

Integumentary 4 abdominal incisions from laparoscopic procedure sealed with surgical glue. No drainage, redness, or edema present.

Musculoskeletal Reported chronic knee pain. 5+ strength in bilateral upper extremities, 5+ strength in bilateral lower extremities.

A parent asks the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae type b (Hib) conjugate vaccine. Which instruction should the nurse provide?

An older adult client with a history of heart failure is admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Patient Data

Review of History, Physical, and Laboratory Results

Based on the findings, indicate whether each represents a modifiable risk factor, a non-modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

The nurse is caring for a client with a history of type 2 diabetes mellitus and hypertension who arrives at the clinic for a scheduled visit. Which finding requires further follow-up by the nurse?
Creatinine: Female: [0.5 to 1.1 mg/dL (44 to 97 µmol/L)], Male: [0.6 to 1.2 mg/dL (53 to 106 µmol/L)]

One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs include oral temperature 99.0°F (37.2°C), heart rate 110 beats/minute, respiratory rate 30 breaths/minute, and blood pressure 160/90 mm Hg. The client's skin is pale, and the surgical dressing is dry and intact. Which intervention is most important for the nurse to implement?

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.