Patient Data

Exhibits

As a result of the Adult Protective Services investigation, additional care has been established for the client including physical and occupational therapy twice weekly and a home health aide to provide assistance with activities of daily living.

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To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client's

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and

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In caring for a client with chronic kidney disease (CKD), the nurse notes that the client's serum phosphate level is elevated, with a converse decrease in serum calcium. Which nursing care goal is a priority, based on these laboratory findings?

A client is receiving IV fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first?

The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image)

An older female client who resides at an assisted living facility comes for an annual gynecological visit at the clinic and states she has a burning sensation when urinating. Assessment findings include: blood pressure 128/88 mm Hg, urine negative for bacteria, and ecchymotic areas on both forearms. She reports being sexually active and drinks beer once or twice a month. During this clinic visit, which intervention(s) should the nurse implement? Select all that apply.

The nurse is caring for a client who is immobile and developed a stage IV pressure injury on the sacrum. The nurse identifies eschar in the wound bed. Which intervention is most important for the nurse to implement?

The nurse is preparing to administer enoxaparin 30 mg subcutaneously using a pre-filled syringe containing 30 mg in 0.3 mL. Which action should the nurse implement?

Patient Data

For each focused assessment area, click to specify which findings indicate early interventions for an ischemic stroke were effective.

Each focused assessment area may support more than one clinical finding. Each category must have at least one response option selected.

A female client with breast cancer is scheduled to receive a series of radiotherapy (RT). She has red hair, fair skin, and freckles. She tells the nurse that her skin is particularly sensitive to the sun, so she is worried that the radiation will adversely affect her skin. Which information should the nurse provide this client about RT? Select all that apply.

The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?

A client is admitted for blunt force chest trauma following a motor vehicle collision. A nasogastric (NG) tube was inserted in the emergency department and chest x-ray results indicate that the tip of the NG tube is in the left chest. Which priority action(s) should the nurse implement? Select all that apply.