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 caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa.

Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?

A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hours.

Which of the following categories of shock should the nurse recognize is occurring?

A nurse is providing teaching to a client who has coronary artery disease. Which of the following statements should the nurse include in the teaching to explain the correlation between changes in the coronary arteries and manifestations that occur?

A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

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 caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath.

Medical History: Nurses Notes: 75-year-old male who reports increased dyspnea for 4 days.
Denies cough or fever.

Past Medical History: Two pack a day smoker for 50 years.

Diagnosed with lung cancer 8 years ago and treated.
Over the last year has developed frequent pleural effusions treated with thoracentesis.

Hypertension.

Surgical History: Right lower lobectomy 4 years ago.

Left hernia repair 25 years ago.
Decreased lung sounds.

The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?