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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 has a prescription for heparin 5000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client’s medication drawer. Which action should the nurse implement?

The home health nurse observes that a female client is using a topical preparation that contains echinacea to treat a canker sore. Her husband expresses concern regarding the effectiveness and safety of using herbs. How should the nurse respond?

The nurse is teaching a client how to use an inhaler device. Which client statement indicates to the nurse that the client understands the instructions?

Patient Data History and Physical The client is a 75-year-old female admitted to the preoperative area to prepare for pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low. She is always tired, and she has passed out once from a low heart rate. Client has a history of worsening symptomatic bradycardia. History of atrial fibrillation controlled by medication. Has been off anticoagulants for 4 days to prepare for the procedure.

Nurses Notes 0700: Laboratory specimens have been drawn and completed during a preadmission visit. After changing clothes and settling into bed, the client was placed on continuous monitoring. Admission process completed. 0800: Peripheral IV (PIV) started in the right antecubital with a 20-gauge catheter. IV fluids of 0.9% sodium chloride started at 50 mL/hr. Cardiac surgeon in to see the client and answer questions about the procedure. 0830: Client reports no known allergies. Vancomycin 1 gram in 250 mL 0.9% sodium chloride started at 125 mL/hr as endocarditis prophylaxis. 0840: Awaiting transfer to the operating room (OR). Vancomycin infusing at 125 mL/hr. 0845: Client states, “I don’t feel well.” Assessment reveals dizziness, headache, burning feeling on extremities, and red color on face and extremities. Blood pressure 108/46 mm Hg. Vancomycin infusion stopped. Surgeon notified. 0850: Client has flushing and redness over the entire body with hives developing. Reports they are feeling hot and nauseous. Cool cloths to face and extremities. Unable to be still in bed. IV fluids of 0.9% sodium chloride infusing at 125 mL/hr. Blood pressure 100/50 mm Hg, heart rate 110 beats/minute. Surgeon to bedside. 0855: Continues with worsening symptoms. Diphenhydramine 25 mg given IV. 0900: Heart rate 90 beats/minute, blood pressure 110/60 mm Hg. Surgeon remains at bedside.

The nurse is evaluating the client’s progress and nursing implementations. Bold the words to highlight the findings that would indicate the client has recovered from the adverse drug reaction.

1230:

The nurse is caring for a client who takes methotrexate for rheumatoid arthritis and receives a prescription for adalimumab. Which instructions should the nurse provide the client?

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 allopurinol. Which information provided by the client requires additional instruction by the nurse?

Patient Data

History and Physical Nurses Notes

History and Physical

The client is a 75-year-old female admitted to the preoperative area to prepare for pacemaker insertion. The client reports she is having this done because her heart rate has been staying very low. She is always tired, and she has passed out once from a low heart rate. The client has a history of worsening symptomatic bradycardia and a history of atrial fibrillation controlled by medication. She has been off anticoagulants for 4 days to prepare for the procedure.

Nurses Notes

0700: Laboratory specimens have been drawn and completed during a preadmission visit. After changing clothes and settling into bed, the client was placed on continuous monitoring. Admission process completed.

0800: Peripheral IV (PIV) started in the right antecubital with a 20-gauge catheter. IV fluids of 0.9% sodium chloride started at 50 mL/hr. Cardiac surgeon in to see the client and answer questions about the procedure.

0830: Client reports no known allergies. Vancomycin 1 gram in 250 mL 0.9% sodium chloride started at 125 mL/hr as endocarditis prophylaxis.

0840: Awaiting transfer to the operating room (OR). Vancomycin infusing at 125 mL/hr.

Question:

The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence.

Sentence: The client is at immediate risk for developing: ______________ , ___________ and ___________.

The nurse is assessing a client who was recently diagnosed with Parkinson’s disease and is taking carbidopa-levodopa. The client is concerned that the medication is not working. Which intervention should the nurse implement first?

The nurse is caring for an adult client who is taking digoxin. Which laboratory value should be reported to the healthcare provider immediately?

Reference Range:

• Sodium: 136 to 145 mEq/L (136 to 145 mmol/L)
• Digoxin level: 0.8 to 2.6 ng/mL (0.6 to 13 nmol/L)
• Potassium (K+): 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)
• Creatinine: 0.5 to 1.1 mg/dL (44 to 97 µmol/L)