Exhibits

Click to highlight the aspects of the assessment that require urgent attention.

0900

Pain assessment completed. The client's pain is 2 on a 0 to 10 pain scale. The client requests sleeping medication for the night. She explains that she keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. Which intervention should the nurse should perform in the immediate management of the client?

An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

The nurse reviews the orders 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.

The nurse on the medical-surgical unit is receiving a transfer report from the postanesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1,000 mL 0.9% sodium chloride is infusing at 125 mL/hr into the left wrist with 600 mL remaining. Ondansetron 4 mg IV every 8 hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain at a level 2 on a 0 to 10 pain scale. The client has a prescription for hydromorphone 1 mg IV every 2 hours PRN for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report?

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?