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An older client who is agitated, dyspneic, orthopneic, and using accessory muscle to breathe
is admitted for further treatment. Initial assessment indicates beats/minute and irregular,
respirations 36 breaths/minute, blood pressure 168/100 mmHg. Wheezes and crackles in all
lung fields. An hour after the administered mg IV, which assessment should the nurse obtain
to determine the client's response to treatment? (Select all that apply)
, Lung Sounds
Oxygen saturation
The nurse is caring for an older male client with impaired skin integrity to sheering forces
and pressure that is manifested as a draining stage 3 sacral ulcer. Which intervention is most
important for the nurse to implement?
Encourage a diet high in protein
While planning care for a client with carpal tunnel syndrome. The nurse identifies a
collaborative problem of pain. What is the etiology of this problem?
Compression of a nerve
A young adult female visits the clinic for primary dysmenorrhea and tells the nurse that she
started taking a calcium supplement to reduce her menstrual cramps. But I quit taking
calcium because it caused constipation. The client to know what she does to relive her
menstrual cramps. Which action should the nurse implement first to address the client's
concern?
Ask her how much calcium she had been taking daily
A client with a medical diagnosis of a ruptured cerebral aneurysm exhibits these symptoms
no eye opening, no sound vocalized, and flexion to pain (decorticate posturing). When
calculating the Glasgow Coma Scale score, Which value should the nurse document for this
client?
5
A client with acute myelogenic leukemia (AML) is admitted to chemotherapy (CT) using
cytarabine and the antitumor daunorubion . Which measures are most important for the nurse
to implement during the induction stage of chemotherapy?
Precautions to prevent infection and bleeding
To reduce pulmonary complications for a client with Amyotrophic Lateral sclerosis (ALS).
Which intervention should the nurse implement? (Select all that apply)
Initiate passives engage of motion exercises
Encourage use of incentive spirometer
Teach the client breathing exercises
A client with polycystic Kidney is admitted because of an abrupt onset of massive polyuria.
The client is pale, tachycardia and female. Which serum laboratory finding requires
immediate intervention by the nurse?