Review H and P and nurses’ notes.

Exhibits

Click to highlight which assessment findings should the nurse attend to right away?

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.

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Patient Data

Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions.

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The client receiving epidural anesthesia would be at risk for developing

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider (HCP), the nurse receives several prescriptions for the client, including a STAT computerized tomography (CT) scan of the head. Which intervention should the nurse perform in the immediate management of the client?

Patient Data

Review H and P, nurse's notes, flow sheet, and prescriptions.

Choose the most likely options missing from the statements by selecting from the list of options provided.

The nurse teaches the client about the fetus reactions to labor by

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.

Which intervention is most important for the nurse to include in the plan of care?

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

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.)

Select from statement options to complete the sentence.

To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client's