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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 with chronic lower back pain has been taking ibuprofen PO twice a day for several months. Which assessment is most important for the nurse to complete?

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

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)

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 nurse is providing discharge instructions to a client who has been prescribed gabapentin 300 mg by mouth (PO) three times a day for postherpetic neuralgia. Which symptom should the nurse tell the client to report to the healthcare provider?

A male client receives a scopolamine transdermal patch 2 hours before surgery. Four hours after surgery, the client tells the nurse that he is experiencing pain and asks why the patch is not working. Which action should the nurse take?

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?

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.

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)