Patient DataThe nurse has Implemented additional needed actions.

Exhibits

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected.

The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?

A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory data which reveals a platelet count of 25,000/mm3 (25 x 109/L), which intervention should the nurse include in the plan of care?

Reference Range

Platelets [150,000 to 400,000/mm3 (150 to 400 × 109/L)]

Patient Data

The healthcare provider places orders to determine the extent of the client condition. Drag from Word Choices to complete the sentence.

Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?

Patient Data

History and Physical

A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse reviews the client's history of the presenting illness in the electronic medical record.

Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding(s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.

Reference Range

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Hemoglobin A1C [4% to 5.9%]

Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]

Total Cholesterol [less than 200 mg/dL (less than 5.2 mmol/L)]

The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on botom.)