What advice should a nurse give to a patient who is about to undergo a cystoscopy?

The nurse reviews the nurse’s notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Exhibit 1: Patient’s Medical History

• Height: 5 ft 6 in (168 cm)
• Weight: 140 lb (63.5 kg)
• Delivery: The patient was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.

Exhibit 2: Nurse’s Notes and Flow Sheet

The patient was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra was moderate with small clots, no foul odor noted. The fundus was firm at the umbilicus. The episiotomy edges were well approximated, with no redness, edema, drainage, or ecchymosis. There was no pain, redness, or swelling in the calves.

• Boggy fundus 1 cm above the umbilicus
• Fundus rotated to the right
• Voided 200 mL of clear yellow urine

Exhibit 3: Vital Signs

• Heart rate: 96 beats/minute
• Blood pressure: 90/62 mm Hg

Exhibit 4: Provider’s Prescriptions

• IV infusing at 125 mL/hr
• A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing.

Exhibit 5: Physical Examination Results

• Episiotomy: Intact with no redness
• Body System: Genital/Urinary and Circulatory

For each statement, specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

The client is a 22-year-old female with a history of asthma.

She was diagnosed at the age of 4 years old and has 2 previous hospitalizations for asthma related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week.

She reports taking edible marijuana to relieve severe premenstrual symptoms.

She came to the emergency department when she started having difficulty breathing on a hike.

She took her usual dose of albuterol, but the symptoms did not resolve.

The client’s friend called an ambulance when they noticed her difficulty in breathing.

Click to highlight the assessment findings that require immediate follow up by the nurse.

• The client is admitted to the medical floor.
• She has mild subcostal retractions and is sitting in an upright position.
• Wheezes are noted throughout the lung fields.
• The client is pale.
• She has strong peripheral pulses that are equal bilaterally.
• Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg. Oxygen saturation is 91% on room air.

A nurse is caring for a 44-year-old male client who had an anterior-posterior spinal fusion 3 days ago. The client is experiencing uncontrolled pain and has not had a bowel movement since the surgery. Which actions should the nurse take to assess the client's progress?

Select all that apply.