A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

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 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:

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 is caring for a client with a tracheostomy. The client’s partner has been taught to perform suctioning.

Which of the following actions by the partner should indicate to the nurse a readiness for the client’s discharge?

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 caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, “I can feel the congestion in my lungs, and I certainly cough a lot, but I can’t seem to bring anything up.”

Which of the following actions should the nurse take to help this client?

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?

A nurse is providing teaching to a client who has atrial fibrillation and reports dizziness and palpitations. Which of the following should the nurse understand is the cause of these manifestations?

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