Client is alert and oriented X4. Speech is clear. Condition:
Respirations even, shallow, slight tachypnea. Low- Pneumonia
pitched rhonchi noted in bases bilaterally.
Congestive cough with productive green sputum. Actions:
Cup of green thick sputum at bedside. Abdomen Administer oxygen 2 L via NC
is soft, nontender, non-distended. Active bowel Administer acetaminophen for fever
sounds X4 quadrants.
5/5 strength noted in lower extremities. Left hip Monitor:
dressing, adhesive tape is peeling, not intact. Oxygen saturation
Client reports hip pain is 3/10. Temperature
100/81
Heart Rate
95
Respiratory Rate
20
Temperature
100.9 °F
38.3 °C
Sp02
88% RAA client had total hip arthroplasty 2 days
ago, and the nurse prepares to change the client's
dressing.
Past medical history includes obesity, severe
osteoarthritis, and hypertension.
History of smoking for two years; discontinued
smoking six months prior to surgery.
Review the electronic health record.
,Complete the diagram by dragging from the
choices below to specify what condition the client
is most likely
A client prescribed phenytoin for the treatment of -Slurred speech
frequent tonic-clonic seizures has a phenytoin -Ataxia
level of 38 mcg/mL (Therapeutic range: 10-20 -Nystagmus
mcg/mL). -Coma
Which findings is the nurse likely to observe
related to this laboratory result? Select all that
apply.
0630 Start IV fluids and obtain blood samples for culture and sensitivity to
Client admitted from the skilled nursing facility start antibiotics.
with Stage IV pressure injury 6 cm x 4 cm with a
depth of 2 cm. Foul-smelling purulent drainage
and areas of eschar present on the left side of the
wound. Temperature 99.6 °F (37.6 °C), heart rate
88, respiratory rate 22, blood pressure 110/68, 02
saturation 94%
The nurse reviews the nursing note from the
previous shift for a 79-year-old client.
What is the nurse's priority action?
,The nurse cares for an 81-year-old client with an Urine output is 240 mL in 8 hours
indwelling catheter for urinary incontinence and
retention.
What assessment result supports the nurse
removing the catheter?
The emergency department nurse cares for a Prepare to administer intravenous naloxone.
client brought in with a respiratory rate of 6, blood
pressure 90/54, and unresponsive to voice. The
nurse assesses multiple needle track marks on
both arms.
What is the priority action by the nurse?
The nurse cares for a client with a tracheostomy Inflate the cuff to 20 cm H₂O
and notes a cuff pressure of 12 cm H20.
What is the priority action by the nurse?
, 1500 Activity tolerance
Crackles auscultated in bilateral lung bases. Client
reports they can ambulate to the bathroom and
back without shortness of breath.
Temperature 98.2 °F (36.8 °C), heart rate 86,
respiratory rate 18, blood pressure 140/68.
A client is prescribed furosemide 40 mg PO daily
for left-sided heart failure.
What documented assessment data indicates to
the nurse that the treatment is effective?
Respirations even, shallow, slight tachypnea. Low- Pneumonia
pitched rhonchi noted in bases bilaterally.
Congestive cough with productive green sputum. Actions:
Cup of green thick sputum at bedside. Abdomen Administer oxygen 2 L via NC
is soft, nontender, non-distended. Active bowel Administer acetaminophen for fever
sounds X4 quadrants.
5/5 strength noted in lower extremities. Left hip Monitor:
dressing, adhesive tape is peeling, not intact. Oxygen saturation
Client reports hip pain is 3/10. Temperature
100/81
Heart Rate
95
Respiratory Rate
20
Temperature
100.9 °F
38.3 °C
Sp02
88% RAA client had total hip arthroplasty 2 days
ago, and the nurse prepares to change the client's
dressing.
Past medical history includes obesity, severe
osteoarthritis, and hypertension.
History of smoking for two years; discontinued
smoking six months prior to surgery.
Review the electronic health record.
,Complete the diagram by dragging from the
choices below to specify what condition the client
is most likely
A client prescribed phenytoin for the treatment of -Slurred speech
frequent tonic-clonic seizures has a phenytoin -Ataxia
level of 38 mcg/mL (Therapeutic range: 10-20 -Nystagmus
mcg/mL). -Coma
Which findings is the nurse likely to observe
related to this laboratory result? Select all that
apply.
0630 Start IV fluids and obtain blood samples for culture and sensitivity to
Client admitted from the skilled nursing facility start antibiotics.
with Stage IV pressure injury 6 cm x 4 cm with a
depth of 2 cm. Foul-smelling purulent drainage
and areas of eschar present on the left side of the
wound. Temperature 99.6 °F (37.6 °C), heart rate
88, respiratory rate 22, blood pressure 110/68, 02
saturation 94%
The nurse reviews the nursing note from the
previous shift for a 79-year-old client.
What is the nurse's priority action?
,The nurse cares for an 81-year-old client with an Urine output is 240 mL in 8 hours
indwelling catheter for urinary incontinence and
retention.
What assessment result supports the nurse
removing the catheter?
The emergency department nurse cares for a Prepare to administer intravenous naloxone.
client brought in with a respiratory rate of 6, blood
pressure 90/54, and unresponsive to voice. The
nurse assesses multiple needle track marks on
both arms.
What is the priority action by the nurse?
The nurse cares for a client with a tracheostomy Inflate the cuff to 20 cm H₂O
and notes a cuff pressure of 12 cm H20.
What is the priority action by the nurse?
, 1500 Activity tolerance
Crackles auscultated in bilateral lung bases. Client
reports they can ambulate to the bathroom and
back without shortness of breath.
Temperature 98.2 °F (36.8 °C), heart rate 86,
respiratory rate 18, blood pressure 140/68.
A client is prescribed furosemide 40 mg PO daily
for left-sided heart failure.
What documented assessment data indicates to
the nurse that the treatment is effective?
