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.

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using SBAR (Situation. Background, Assessment, Recommendation) communication, which information should the nurse provide first?

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

According to the lab values, the client has

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 with multiple sclerosis (MS) is receiving interferon beta-1b 0.1875 mg SUBQ every other day. The nurse reconstitutes the vial by slowly injecting "2 mL of diluent into the interferon vial for a reconstituted solution of 0.25 mg/1 mL How many mL should the nurse administer?

(Enter numeric value only. If rounding is required, round to the nearest hundredth.)

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?