Patient Data

Exhibits

What can the nurse do to help the parents decrease their anxiety? Select all that apply.

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

While the nurse is preparing a scheduled IV medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

A school-aged client is receiving vancomycin, 400 mg IV every 6 hours for a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. The medication is diluted in a 100 mL bag of 0.9% sodium chloride with instructions to infuse over one and a half hours. How many mL/hour should the nurse program the infusion pump? (Please enter the numeric value only. If rounding is required, round to the nearest whole number.

A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition?

A nurse is caring for a client with binge eating disorder. Which goal should the nurse establish first with the client?

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 client has received a prescription for a fluid bolus of 0.9% sodium chloride, 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver? (Please enter the numerical value only.)

The question is asking for the rate at which the infusion pump should be programmed to deliver a fluid bolus of 200 mL in 30 minutes. This can be calculated using the formula for rate which is volume divided by time.

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?