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 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?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Patient Data

The nurse is linking the client's symptoms to the most likely pharmacologic treatment.

Choose the most likely option for the information missing from the statement by selecting from the list of options provided.

The most appropriate medication class to treat the client's presentation is a

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. Which nursing intervention is best for the nurse to implement?

To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

A client with Parkinson's disease receives a prescription for benztropine. Which common adverse effect(s) should the nurse include in the teaching plan? Select all that apply

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide?

A client who was discharged 3 days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen left lower leg. The nurse is preparing to initiate heparin therapy. Which additional intervention should the nurse include in this client's plan of care?

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

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)]