Patient Data

Exhibits

Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Click to highlight the findings that would indicate the client is progressing and ready for an epidural.

0245

Peripheral IV (PIV) started in left hand with 20 gauge catheter. Lab specimens drawn. IV fluids of lactated Ringer's started Infusing at 75 mL/hour. Contractions are now every 4 minutes lasting 45 seconds. Mother says they are getting more painful. Instructed her and husband on slow breathing and relaxation techniques. Husband will assist wife breathing. Client instructed she can have IV pain medication if she needs it until time for epidural.

0330

Contractions are now every 3 to 4 minutes apart and client reports they are really hurting. Asking for epidural. Healthcare provider (HCP) to bedside. SVE reveals 5 cm dilated, 90% effaced and 0 station. Performed artificial rupture of membranes with clear amniotic fluid.

A client who weighs 22 pounds receives a prescription for amoxicillin 50 mg/kg/day PO in divided doses every 8 hours. The bottle is label "Amoxicillin for Oral Suspension, USP 250 mg per 5 mL". How many mL should the nurse administer with each dose?

(Enter numerical value only. If rounding is required, round to the nearest tenth.)

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

Patient Data

The nurse reviews the prescriptions 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 option selected.

Patient Data

Select the 4 assessment findings that require immediate follow up.

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin- resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

The nurse uses the Modified Caregiver Strain Index (MCIS) and determines that the daughter is under significant stress caused by the assumption of her mother's care. The nurse is planning to have a discussion with the daughter on decreasing the stress she is experiencing as a caregiver.

Select the 3 statements that the nurse should include when discussing caregiver stress with the client's daughter.

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

Review H and P and nurses’ notes.

Click to highlight which assessment findings should the nurse attend to right away?

Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids.