Patient Data

Exhibits

The nurse has identified the priority problem for the client and now must determine proper care interventions.

Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?

Patient’s Data

Select the 3 dietary choices that are not part of the recommended diet gout.

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 nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?

A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with 0.9% sodium chloride is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag.

Which action should the nurse take?

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)]

A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

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.)

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

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