Take full exam for free

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?

To control asthma, a client in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system, which provides an inhaled powdered form of these combined medications. Which instruction should the nurse provide to this client’s caregivers?

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

The nurse is administering sodium polystyrene sulfonate to a client in acute kidney injury (AKI). Which laboratory finding indicates that the medication has been effective?

The nurse is administering sodium polystyrene sulfonate to a client in acute kidney injury (AKI). Which laboratory finding indicates that the medication has been effective?

Reference Range:

• Glucose: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)
• Hemoglobin: 14 to 18 g/dL (140 to 180 g/L)
• Potassium: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)
• Ammonia: 10 to 80 µg/dL (6 to 47 µmol/dL)

A client who is taking an oral contraceptive receives a new prescription for erythromycin. Which instruction should the nurse provide to the client?

A client who is newly diagnosed with diabetes insipidus (DI) is receiving synthetic vasopressin intravenously. Which side effect of vasopressin reported by the client should the nurse report to the healthcare provider?

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?

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

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 providing medication teaching to a client with bipolar disorder who receives a prescription for lithium carbonate. Which instruction should the nurse emphasize with the client?

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 ___________.