A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

Increased heart rate.

Discomfort at the puncture site.

A nurse is monitoring a client following a thoracentesis.

The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

f 55. A nurse is analyzing a client’s electrocardiogram (ECG) strip and identifies the following information:

Heart rate: 92/min.
Rhythm: Irregular.
P wave: Unable to identify.
PR interval: Unable to measure. QRS duration: 0.10 seconds.

Based upon this information, the nurse should interpret the client’s rhythm as indicating which of the following?

A nurse on a cardiac care unit is caring for a preschooler.

• Hospital Day 1, 17:38: Medication Administration Record.
• 20:15: Received 4-year-old child with an exacerbation of heart failure.
• Family reports history of congenital mitral stenosis.
• Breath sounds with wheezing noted in bilateral lower lobes.
• Nonproductive cough noted.
• Dyspnea with respiratory rate 30/min.
• Oxygen at 2 L/min applied per nasal cannula.
• Telemetry applied: Sinus rhythm at rate 116/min. Abdomen soft, nontender.
• Bowel sounds positive in all 4 quadrants. Lower extremities with 2+ edema noted.
• Pedal pulses palpable bilaterally.
• Peripheral saline lock intact to right forearm with no signs and symptoms of infection.
• Weight 26 kg (44 lb). Increase in dyspnea noted with orthopnea.
• Nasal flaring with respiratory rate of 36/min.
• Lung sounds with wheezing noted throughout.
• Lower extremity edema 3+ to bilateral lower extremities.
• Extremities cool with decreased skin pigmentation noted.
• Peripheral pulses weak bilaterally.
• Jugular vein distention noted.
• Provider notified.

Received prescription for additional dose of furosemide. The client is at risk for developing:

A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

A nurse is caring for a school-age child who has leukemia.

0900: Custom Nursing Assessment.
1000: Vital Signs: Child is awake and alert but not talkative.

Child was brought in for an ongoing upper respiratory infection for the last 2 months that will not go away. Parents report the child’s leukemia has been in remission for more than a year.
Bruising noted on the child’s shoulder, thighs, and back.

Parents are not sure where it came from.
Diagnostic Results: Child’s breath sounds clear with subcostal retractions.

Oxygen saturation is 92% on room air.
Child’s skin is pale and petechiae noted on trunk and thighs.

Child states, “I feel like I can’t breathe.”. Bed raised to high-Fowler’s, oxygen applied and provider notified.

Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.

A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?