Patient Data

 

 

Exhibits

 

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.

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client verbalizes that he is tired of fighting this illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

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.

Patient Data

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Patient Data

The nurse reviews the prescriptions and plans initial steps for caring for the client.

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

A client with foul smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

An older male client who is admitted to a rehabilitation facility manifests signs of acute dementia. The nurse observes the client repeatedly calling out for his deceased spouse to come and get him. Which intervention(s) should the nurse implement? Select all that apply.

A client with a history of alcohol addiction says, "My body feels fine when I abstain from alcohol consumption, but I miss my late night glasses of wine." Which concept should the nurse discuss with the client?

Patient Data

Click to highlight the findings that would indicate the client is progressing as expected.

The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.