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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?

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?

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?

The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?

Which intervention is most important for the nurse to implement for a client with type 2 diabetes mellitus (DM) who is receiving insulin lispro?

A female client starts a new prescription, oxybutynin, for symptoms of an overactive bladder. The client tells the nurse that she is training to run in a half-marathon. Which instruction should the nurse emphasize?

Patient Data

History and Physical Notes

Flow Sheet

History and Physical

A 23-year-old female presents to the emergency department with altered mental status. She is accompanied by her roommate. The roommate says that symptoms started around 0900 today and have progressively worsened. She says the client first appeared euphoric but would switch to being irritable. The client also reported diarrhea and nausea. The client is combative. The client has a history of major depressive disorder and is being treated with paroxetine 50 mg PO once daily.

Nurse Notes

1830

The nurse notes significant diaphoresis. The client appears confused and disoriented to person, place, and time. Lung sounds are clear. No arrhythmia is noted. Palpated pulses are strong and bounding. Capillary refill is less than 3 seconds. Intermittent rigidity with myoclonus is noted in both upper extremities.

Flow Sheet

Day 1, 1830

Vital Signs

• Temperature 102°F (38.8°C)
• Heart rate 118 beats/minute
• Respirations 16 breaths/minute
• Blood pressure 168/94 mm Hg
• Oxygen saturation 97% on room air
• Height 5 feet, 4 inches (64 cm)
• Weight 136 pounds (61.6 kg)

Question:

Which assessment findings require follow-up by the nurse? Select all that apply.

Patient Data

History and Physical

The client is a 36-year-old female with moderate persistent asthma. She takes fluticasone/salmeterol 250 mcg/50 mcg, 1 inhalation twice daily, and albuterol 90 mcg/inhalation, 2 inhalations every 4 to 6 hours PRN.

Nurses’ Notes

The client reports that she has had more severe asthma symptoms than usual in the past week. Her forced expiratory volume has been 60 to 65% even with multiple doses of albuterol for several days in a row. She came to the hospital feeling dizzy, lightheaded, and reporting “heart palpitations.” Upon assessment, no wheezes were found. Her oxygen saturation is 99% on room air.

Review H and P, and nurse’s note. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Actions to Take Parameters to Monitor potential condition Actions to Take Parameters to Monitor

The nurse notifies the healthcare provider (HCP) that the client is having trouble remembering to take his second dose of captopril. What angiotensin-converting enzyme (ACE) inhibitors can be given only once per day? Select all that apply.

A client is receiving orlistat as part of a weight management program. Which ongoing assessment should be included in the plan of care to determine the effectiveness of the medication?

A client with peptic ulcer disease receives a new prescription for cimetidine. Which statement provided by the client requires additional instruction by the nurse?