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1. Avnursevinvavmedical-surgicalv unitvisvcaringvforvsixvclients.
Completevthevfollowingvsentencevbyvusingvthevlistvofvoptions.
Thevfirstvclientvthevnursevshouldvassessvis followedvby _
Clientv1:Clientvisadmittedwithanewdiagnosisofrheumatoidvarthritis.Client2:v
Clienthasahistoryvofhyperlipidemia.vAtorvastatinv 20vmgvPOadminis-
vteredvasvprescribed.Clientv3:Clientisv1daypostoperative.vReportsvpainva
s
8vonv avscalevofv 0vtov 10.vMorphinev 5vmgvsubcutaneousv administeredv asv
pre-
scribed.Clientv4:vClientvisvadmittedvwithvavnewvdiagnosisvofvheartvfailure.C
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, lients:vClientvhasvavstagev2vpressurev injuryv onvthevleftvheel.Clientv 6:vClie
ntvisvadmittedvwithv avnewvdiagnosisvofvdiabetesvmellitus.:
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, CorrectvAnswerv(1):
Clientv3
Whenvusingvthevairway,vbreathing,vcirculationvapproachvtovclientvcare,vthe
vnursevshouldv determinev thatvthisv clientvisvthevpriorityv clientvtovassess.v
Thevclientvhasvanvoxygenvsaturationvthatvisvlessvthanvthevexpectedvreferen
cevrange,vwhichvisvanvindicationvofvhypoxia.
CorrectvAnswerv(2):
Clientv4
Whenvusingvthevairway,vbreathing,vcirculationvapproachvtovclientvcare,vthevnurs
evshouldvdeterminevthatvthisvclientvisvthevnextvpriorityvclientvtovassess.vThevcl
ientvhasavpotassiumvlevelvthatvisvlessvthanvthevexpectedvreferencevrange,vwhich
vplacesvtheclientvatvriskvforvdysrhythmias.
In
CorrectvAnswersv(1):
Clientv 1visvincorrect.vThevnursev shouldv assessvthisv clientvbecausev thev client'sv
C-re-
activevproteinvisvgreatervthanvthevexpectedvreferencevrange,vwhichvisvanvindicati
onvofvinflammation.vHowever,vtherevisvanothervclientvthevnursevshouldvassessvfi
rst.
Clientv2visvincorrect.vThevnursevshouldvassessvthisvclientvbecausevthevclient'svc
holesterolvlevelvisvgreatervthanvthevexpectedvreferencevrange,vwhichvplacesvthe
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, mvatvriskvforvcoronaryvheartvdisease.vHowever,vtherevisvanothervclientvthevnurs
evshouldvassessvfirst.
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7/14/2024, 6:44 PM