Patient Data

Exhibits

Which interventions are indicated to promote positive outcomes for the patient? Select all that apply.

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Patient Data

The nurse reviews the post catheterization orders.

Which two orders would the nurse question?

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.

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)]

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?

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?

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include a sodium of 129 mEq/L (129 mmol/L), a glucose of 54 mg/dL (2.97 mmol/L), and a potassium of 5.3 mEq/L (5.3 mmol/L). When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication?
Reference Range:
Sodium [136 to 145 mEq/L (136 to 145 mmol/L)],
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)],
Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?