Exhibits

A nurse is caring for a 44-year-old male client who had an anterior-posterior spinal fusion 3 days ago. The client is experiencing uncontrolled pain and has not had a bowel movement since the surgery. Which actions should the nurse take to assess the client's progress?

Select all that apply.

The nurse is reviewing the clients’ chart. Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage

History and Physical A 36-year-old client who is gravida 5 para 5 (GSP5) transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was in labor for 25 hours and forceps were used to assist with the delivery. She was given an epidural for anesthesia that was effective. The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale. Her vital signs were stable, and she was catheterized for 500 mL of light yellow urine just prior to delivery. Her spouse was at the bedside for delivery and appeared supportive. Blood type A+. Estimated blood loss was 600 mL after delivery.

Nurses’ Notes Received GSP5 client 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was assisted to the bathroom where she voided 150 mL clear yellow urine. Lochia rubra moderate with small clots, no foul odor noted. Fundus firm at umbilicus. Episiotomy edges well approximated, no redness, edema, drainage, or ecchymosis. No pain, redness or swelling in calves. A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18 gauge peripheral IV in the left forearm at 125 mL/hr, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

The nurse is assessing a 4-year-old patient with eczema.
The child’s skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding.
What guideline is indicated for care of this child?

A patient with primary hypothyroidism is showing early signs of myxedema coma.
In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

A child weighing 55 lb has been prescribed cefotaxime at a dosage of 150 mg/kg/day, to be administered in divided doses every 6 hours.

How many mg should the nurse administer each day? (Provide a numerical value only.)

The client is a 22-year-old female with a history of asthma.

She was diagnosed at the age of 4 years old and has 2 previous hospitalizations for asthma related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week.

She reports taking edible marijuana to relieve severe premenstrual symptoms.

She came to the emergency department when she started having difficulty breathing on a hike.

She took her usual dose of albuterol, but the symptoms did not resolve.

The client’s friend called an ambulance when they noticed her difficulty in breathing.

Click to highlight the assessment findings that require immediate follow up by the nurse.

• The client is admitted to the medical floor.
• She has mild subcostal retractions and is sitting in an upright position.
• Wheezes are noted throughout the lung fields.
• The client is pale.
• She has strong peripheral pulses that are equal bilaterally.
• Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg. Oxygen saturation is 91% on room air.