Exhibits

Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

An older adult client who cares for her husband at home has just learned that she needs to have knee replacement surgery. She tells the nurse she is concerned about her inability to provide care to her husband while she recovers from surgery and attends physical therapy. She has a friend who can drive her to and from her appointments once she is discharged, but cannot provide the care her husband needs.

How should the nurse respond to the client?

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Patient Data

Review H and P. nurse's notes, laboratory results, flow sheet, and prescriptions. Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus.

Each column must have a least one response selected.

When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?

Click to highlight the findings that require follow up.

Neurological: Alert and oriented. Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Gastrointestinal: Within normal limits (WNL).

Genitourinary: WNL

Musculoskeletal: WNL

Pain: 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

A client presents to the clinic with fatigue, poor appetite, general malaise, and vague joint pain that improves mid-morning. The client has been taking over-the-counter Ibuprofen for several months. The healthcare provider makes an initial diagnosis of rheumatoid arthritis (RA). Which laboratory test(s) should the nurse report to the healthcare provider? Select all that apply.

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.

Which intervention is most important for the nurse to include in the plan of care?

A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. The vital signs are assessed as a temperature of 99.6° F (37.5° C), heart rate 98 beats/minute, respirations 28 breaths/minute, blood pressure 140/82 mm Hg, and a oxygen saturation 889% on room air.

Which action should the nurse implement?