An adult client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?

A client is being cared for in the emergency department with acute abdominal pain and a provisional diagnosis of pancreatitis. The nurse assesses the client and obtains the results from laboratory studies. Which information is most valuable in reporting the client's status to the healthcare provider?

Patient Data

A teenage client is admitted to the emergency department following a bee sting. The client arrives with a body rash and 30 minutes later becomes short of breath. The nurse obtains the client's vital signs as a heart rate of 130 beats/minute, respirations of 40 breaths/minute, and a blood pressure of 90/52 mm Hg. The client is exhibiting clinical manifestations of which type of immune reaction?

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

Three days after a cholecystectomy for cholelithiasis, a client reports persistent upper abdominal pain that radiates to the back. The client has vomited three times in the last 12 hours and has a temperature of 101.8°F (38.7° C). Serum amylase and lipase are twice the normal value. Based on these findings, the nurse should observe the client for which pathophysiological condition?

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow- up action by the nurse?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

A client has a nasogastric (NG) tube placed during abdominal surgery. During postoperative convalescence, the nurse identifies that the client is manifesting a hand tremor, muscle twitching, and confusion. Which arterial blood gases consistent with metabolic alkalosis should the nurse report to the healthcare provider?

Reference Range pH 17.35 to 7.45]

PaCO2 135 to 45 mm Hg]

HCO3 [21 to 28 mEq/L or 21 to 28 mmol/L]

PaO2 [80 to 100 mm Hg]