Take full exam for free

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.

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

A client is being cared for in the emergency department with acute abdominal pain and a provisional diagnosis of pancreatitis. Which information is most valuable in reporting the client’s status to the healthcare provider?

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?

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?

A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

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?

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

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 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?