Patient Data

Exhibits

The nurse has identified the priority problem for the client and now must determine proper care interventions.
Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

A client with a renal calculus reports severe right flank pain, nausea, and vomiting.
Which nursing problem has the highest priority?

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

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 is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?

The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/mL. How many mL should the nurse administer to this client?

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

Patient Data

The nurse has implemented additional needed actions.

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected.

Assessment Data: Indicates the Interventions Were Successful/ No Indication that the Interventions Were Successful

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?