Patient Data

Exhibits

The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.

What interdisciplinary team member(s) should assist the client in recovery? Select all that apply.

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?

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)]

Patient's data

Which assessment findings require follow up by the nurse? Select all that apply.

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

The nurse implements a secondary prevention program for sexually transmitted infections in a local health center. Which outcome indicates that the program was effective?

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

The nurse of a medical-surgical unit receives a report from a postanesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an IV infusion of 1,000 mL lactated Ringer's infusing at 125 mL/hr into the left wrist with 300 mL remaining. Prescriptions include morphine sulfate 2 mg IV every 2 to 4 hours for pain, last administered 30 minutes ago; ondansetron 4 mg IV every 8 hours for nausea, last administered 15 minutes ago." Which additional information is most important for the nurse to obtain in the report?