Reference Range:

Body mass index (BMI) [18 to 24.9 kg/m3]

 Click to highlight the findings that require follow up

Neurological: Alert and oriented. Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Patient Data

The nurse is stabilizing the client and preparing her for surgery.

Which goals should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

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?

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

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?

Highlight the findings that require immediate follow up.

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. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members.

Following a gunshot wound, an adult client has a hemoglobin level of 4 g/dL (40 g/L). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement?

Reference Range

Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Patient Data

The client has recovered from surgery and is ready to be discharged.

Highlight findings that indicate the client is stable and ready to be discharged.

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?