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A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

. The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

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?

Three days after a cholecystectomy for cholelithiasis, a female client reports having persistent upper abdominal pain that radiates to her back. She has vomited three times in the last 12 hours and has a temperature of 101.8° F. (38.7° C). Serum amylase and lipase are twice the normal value. Based on these findings, the nurse should observe the client for which pathophysiological condition?

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Patient Data

History and Physical

The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20.

Nurses' Notes

0815

Vital signs

• Temperature 97.5° F (36.4° C)

• Heart rate 104 beats/minute
• Respirations 29 breaths/minute
• Blood pressure 119/82 mm Hg
• Oxygen saturation 89% on room air

Oxygen mask applied.

0830

• Oxygen saturation 97% on 10 L/min oxygen via face mask

Orders

0800

• Admit to the medical floor

• Vital signs every 4 hours
• Continuous pulse oximetry
• Supplemental oxygen 10 L/min via nasal cannula
• Enalapril 10 mg PO every morning
• Ibuprofen 400 mg PO every 4 to 6 hours PRN for temperature greater than 100.5° F (38.0° C)
• Send blood for a complete blood count, electrolytes
• Chest x-ray now

0815

• Supplemental oxygen 10 L/min via simple face mask

Imaging Studies

Chest x-ray: Consolidation noted in the right middle and lower lobe consistent with pneumonia

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

Based on the information that the nurse has about the client, he likely has --------------------------  related to ------------------------------

Blank 1

Toxicity

Anemia

Dysrhythmia

hypoxia

Blank 2

Diminished concentration of inhaled oxygen

Airway obstruction

Diminished concentration of inhaled oxygen

Blood stream Infection

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

A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

. A teenage client is admitted to the emergency department following a bee sting. The client arrives with a body rash and 30 minutes later becomes short of breath. The nurse obtains the client's vital signs as a heart rate of 130 beats/minute, respirations of 40 breaths/minute, and a blood pressure of 90/52 mm Hg. The client is exhibiting clinical manifestations of which type of immune reaction?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?