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The nurse reviews the arterial blood gas results of an assigned client and notes the laboratory report results

pH of 7.30, [normal pH is 7.35 to 7.45]

Paco2 of 58 mm Hg, [Normal Paco2 is 35 to 45 mm Hg]

Pao2 of 80 mm Hg. [normal is 80-100]

HCO3 of 27 mEq/L (27 mmol/L). [Normal HCO3 is 22-26]

The nurse interprets that the client has which acid-base disturbance?

A nurse is caring for a client and observes that the client's urine is cloudy, has an unpleasant odor, and contains hematuria. The nurse should recognize that these findings are associated with which urinary problem?

Which technique would the nurse use to perform scoliosis screening in a school-age child?

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which assessment data is an expected finding?

A nurse in an emergency department is caring for a client who has abdominal pain.

Nurses' Notes 

0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk."

0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily.

0915: Fecal mass of hard, dry stool removed digitally from client per provider's order.

1015: Provided teaching to client and partner about constipation and methods to avoid further impaction.

Diagnostic Results

0900:

Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction.

A nurse is providing teaching to a client who has constipation. Which information should the nurse include? (Select all that apply.)

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which action should the nurse take?

A nurse is precepting a nursing student. The nurse explains to the nursing student how you would perform the graphesthesia test on a client. What is the correct way to perform this test?

A nurse has been assigned four patients, of which one of the patients has impaired immobility. Which complications should the nurse expect as a result of gout? (Select the four options that apply.)

Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes. You have noted a group of lesions larger than 0.5 cm, with an elevated area of psoriasis. This is an example of a:

 A nurse in an emergency department (ED) is admitting a client.

Vital Signs 

1000:

Temperature 38.6° C (101.5° F)

Heart rate 106/min

Respiratory rate 26/min

Blood pressure 110/54 mm Hg

Oxygen saturation 94% on room air

Nurses Notes 

1000:

Client presents to ED with report of shortness of breath for 3 days, with headache, chills, fever, sore throat, and cough.

Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.

Client's face is flushed, sinus tachycardia, rate of 106/min, $152 heart sounds heard on auscultation. Pulses palpable.

Breath sounds with crackles to right lower lobe, tachypnea, rate of 26/min. Tactile fremitus and decreased lung expansion noted upon assessment. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."

Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."

Reports decreased urination in the past day.

Client reports they have not had a pneumococcal vaccine. States, "1 Just hate needles."

Diagnostic Results

1030:

Chest x-ray.

Areas of increased density and white infiltrates to lower right lobe.

Select 3 objective findings in the client's medical record that may be indicative of pneumonia.