A nurse is caring for a neonate in the neonatal intensive care unit. Q122

Exhibits

Which findings in the client's electronic medical record (EMR) are risk factors for the client developing a complication? Select all that apply.

A nurse is caring for a client.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?

A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy

The nurse is continuing to care for the client.

A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed? For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator. Which of the following information should the nurse include?

A nurse working in the emergency department (ED) is admitting a client.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

Day 1, 1030:

Client reports feeling short of breath, productive cough with yellow sputum, and pleuritic chest pain. Runny nose, myalgia along with headache for the past 3 days. "I woke up feeling worse and started to feel nauseated and couldn't eat my breakfast, so I thought I should come in." Client reports pleuritic chest pain as 6 on a scale of 0 to 10. Skin is moist. Lungs sounds are diminished in lower lobes with crackles. Bowel sounds are normoactive in all quadrants. Last bowel movement this morning. Reports no difficulty urinating. Reports nausea with no vomiting. Able to move all extremities. Pedal pulses present +2. Client is oriented to person, place, and time.

A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?

A nurse is caring for a client.

Complete the following sentence by using the lists of options.

The nurse understands that the patient has likely developed

A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 min ago. The client is lethargic and a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?

A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care?