Patient Data

 

Exhibits

Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

Based on the client's history, physical and laboratory findings, the priority need will be to treat

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, in addition, the client will need interventions to manage complications, especially

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.

The nurse on the medical-surgical unit is receiving a transfer report from the postanesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1,000 mL 0.9% sodium chloride is infusing at 125 mL/hr into the left wrist with 600 mL remaining. Ondansetron 4 mg IVP every 8 hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain rated 2 on a 0 to 10 scale. The client has a prescription for hydromorphone 1 mg IVP every 2 hours PRN for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report?

A client diagnosed with glaucoma receives a new prescription for dorzolamide. Prior to administering the medication, the nurse should review the electronic medical record for which allergy?

The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

Patient Data

The nurse is anticipating which additional medications the healthcare provider may prescribe for the client to manage side effects while on morphine sulfate.
Select the 3 medications that would be most appropriate to manage the side effects of morphine sulfate.

A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hour. The available solution is "Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL". The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding?

Patient Data

Review H and P and nurse's notes.

Click to highlight which assessment finding(s) should the nurse attend to right away?

Admitted client.

Vital signs

Temperature: 96.9° F (36.1° C) internal probe via urinary catheter

Heart rate: 128 beats/minute, sinus tachycardia (ST)

Respirations: 14 breaths/minute

Patient Data

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg

Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2)

The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a PIV line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members. The client opens her eyes to verbal stimuli and follows verbal commands.

The nurse is evaluating the client’s response to pain management.

Click to highlight the findings that indicate the client is experiencing the therapeutic effects of the medication.

Pain level presently 3 on a 0 to 10 scale. The client reports feeling “sleepy.” Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer. New mild cough noted. Repositions in bed with minimal assistance. Attempted to get up to the chair, but experienced dizziness with standing.