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A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

To assess the quality of an adult client’s pain, which approach should the nurse use?

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

A client with emphysema is reporting difficulty in breathing and exhibiting audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

A nurse is caring for a 76-year-old male client in the medical unit

History and Physical

The client is a 76-year-old male with a history of chronic obstructive pulmonary disease (COPD) and hypertension. He presented to the emergency department with a 3-day history of productive cough, fever, and shortness of breath. He has a 40-pack-year smoking history and lives alone. He denies recent travel or sick contacts.

Nurses’ Notes

Day 1, 1800: The client was admitted to the medical unit with suspected pneumonia. Crackles were auscultated bilaterally in the lower lung fields, and breath sounds were diminished. A saline infusion was initiated at 50 mL/hour. Vancomycin IV piggyback (IVPB) was started. Sputum and blood cultures were obtained and sent to the lab.

Diagnostic Results

Day 2: Sputum culture positive for pneumococcus. Chest x-ray showed focal consolidation in the bilateral lower lobes, suggestive of pneumonia.

Vital Signs

• Temperature: 38.5°C
• Heart Rate: 110 bpm
• Respiratory Rate: 24 breaths/min
• Blood Pressure: 150/90 mmHg
• Oxygen Saturation: 88% on room air

Physical Examination Results

On physical examination, the client appeared in moderate respiratory distress. He had crackles bilaterally in the lower lung fields and diminished breath sounds throughout. His skin was warm and diaphoretic. He was using accessory muscles to breathe and had a productive cough with greenish sputum.

Provider’s Prescriptions

• Continue saline infusion at 50 mL/hour
• Discontinue vancomycin
• Start ceftriaxone 1g IV every 24 hours
• Albuterol treatments by nebulizer every 4 to 6 hours
• Increase oral fluids
• Obtain arterial blood gas (ABG)

Imaging Studies

Chest x-ray showed focal consolidation in the bilateral lower lobes, suggestive of pneumonia.

Question: Which of the following does the nurse anticipate the healthcare provider to prescribe during morning rounds? Select 4 findings.

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath and a productive cough with thickened, tenacious mucus. The client reports difficulty walking up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?

A client has a nasogastric (NG) tube placed during abdominal surgery. During postoperative convalescence, which arterial blood gas values are consistent with metabolic alkalosis?