Nursing Care Highlights

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for a dietary consult. The client tells the nurse, "I will have to eat whatever the dietitian tells me." Which of the following statements by the nurse encourages the client's involvement in their plan of care? "I can assist you with making a list of foods you like for the dietitian A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would: Pinch the trapezius muscle. A hospice nurse is planning care for a client who has lung cancer. Which of the following statements should the nurse make to incorporate the client's and family's cultural beliefs? We will respect what is important to you." A nurse is preparing to assist with an ocular irrigation for a client who had a chemical splash to the left eye. Which of the following actions should the nurse plan to take? Place a strip of pH paper under the upper lid of the affected eye A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement? Standard precautions A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority? Rebound tenderness with palpation A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room? A client who reports having fever, night sweats, and cough for 2 days A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity? A client who has a right upper extremity arteriovenous fistula A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status? Altered level of consciousness A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy? "I have a hard time with brushing my hair." A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates the effectiveness of the teaching? "I should expect to take my medication for 3 weeks." A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first? Administer nitroglycerin. A nurse is reinforcing teaching with a client who has osteoporosis and is prescribed (Fosamax) alendronate 70 mg PO weekly. Which of the following statements by the client indicates a need for further instruction? "I take my alendronate on the same day every week with an 8-ounce glass of milk." A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? "I'm going to include more cantaloupe in my diet." A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make? "Your breathing pattern causes this." A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? Weight loss of 1.8 kg (4 lb) in the past 24 hours A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response? Laryngeal edema A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include as an indication that the client is no longer infectious? Negative sputum cultures for acid-fast bacillus A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority? The client reports numbness of the fingers of the left hand A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care? Administer oxygen at 2 L/min A nurse is preparing a client for a magnetic resonance angiography (MRA). The client is allergic to iodinated contrast dye. Which of the following actions should the nurse plan to take? Administer prednisone before the test. A nurse is caring for a client who is receiving morphine through a PCA (Patient-Controlled Analgesia) device. Which of the following actions should the nurse take? Teach the client how to self-medicate using the PCA device. A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over the past 24 hours. The nurse should anticipate a prescription for which of the following intravenous (IV) medications? Desmopressin A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect? Photophobia The nurse is performing pin care for a patient with an external fixation device for a fractured tibia. Which assessment finding by the nurse should be reported to the unit care coordinator? Purulent drainage around pins A nurse is planning care for a client who is receiving targeted radiation therapy to the neck. The nurse should plan to monitor the client for which of the following as an adverse effect of this therapy? Mouth ulcers A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy? Antithrombotic A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take? Provide the client with a trapeze bar. A nurse is reinforcing discharge teaching with a client on how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? Empty the ostomy pouch when it is 2/3 full. A nurse is caring for a client who has a peripherally inserted central catheter (PICC) for the administration of total parenteral nutrition (TPN). The transparent dressing over the insertion site requires replacement. Which of the following actions should the nurse take? Use sterile technique for the procedure. The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain: One tablet SL (sublingual) every 5 minutes, up to 3 times. A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor the client for which of the following manifestations? Severe, throbbing headache A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would: Press down on the trapezius muscle. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (Select all that apply.) Chronic infections of the middle ear Perforation of the eardrum Use of a loop diuretic A nurse is preparing to administer heparin subcutaneously to a client. Which of the following is an appropriate action by the nurse? Use a 25-gauge needle to inject the medication. A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP? Restlessness A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching? The client advances the weaker (left) leg forward to the cane. A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching? "I will draw the regular insulin into the syringe first." A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess their ability to swallow? "Do you feel like you have food stuck at the base of your throat?" A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make? "Did you decrease your insulin intake before you exercised?" A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching? Increased temperature A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first? Lower the client to the floor. A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station? A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash. A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take? Discard samples that contain urine. A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take? Instruct the client to lie flat. A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? Muscle twitching A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hours. Which of the following actions should the nurse take? Slow infusion rate and contact the provider. A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication? Heart rate 48/min A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take? Wear a surgical mask when providing care to the client. A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long-term glycemic control? Glycosylated hemoglobin level A nurse is caring for a client who has acute heart failure and received morphine intravenously 30 minutes ago. Which of the following findings should the nurse identify as an indication that the medication was effective? Decreased anxiety A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hours. Which of the following actions should the nurse take in managing the client's PICC line? Flush the catheter with a 0.9% sodium chloride solution after each use. A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include? "Display a monthly calendar in the client's room." A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results? Uric acid A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching? "I will be sure to wear gloves and wash my hands when I change my cat's litter box." A nurse is planning care for a client who is postoperative following the insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care? Check the pulse distal to the graft A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for increasing the client's dopamine dosage? Blood pressure 90/50 mm Hg A nurse is caring for a client who has developed hives and urticaria following the administration of IV contrast dye after a cardiac catheterization. Which of the following medications should the nurse plan to administer? Diphenhydramine A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room? Oral airway A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement? Use a bed alarm. A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make? "Your provider wouldn't prescribe this medication if it weren't necessary." A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and STsegment elevation. The client reports shortness of breath and feeling dizzy and faint. Which of the following medications should the nurse administer? Atropine A nurse is caring for a client who is using a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? Check the settings of the CPM machine every 12 hours. A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy? Initiate a referral for the client to a home health agency. A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider? 100 mL of red drainage A nurse is planning care for a client who is 12 hours postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care? Assess urine output hourly. A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include? Brush your teeth for 60 seconds twice daily. A nurse is reviewing orders for a patient in anaphylactic shock. Which medication should the nurse plan to administer first? Epinephrine (Adrenaline) A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hours ago. Which of the following findings should the nurse expect? Edema at the site A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment? Gently elevate the client's head and note any nuchal rigidity. A nurse is caring for a group of clients who are 12 hours postoperative. The nurse should identify that the client who had which of the following procedures is at risk for developing fat embolism syndrome? Internal fixation of a fractured hip The nurse is caring for several clients on a hospital unit. Which of the following clients is most at risk for hypoglycemia? A client with type 1 diabetes mellitus who has taken a high dose of insulin A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following pieces of information should the nurse include in the teaching? "Hold your breath for 10 seconds once you inhale." A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include? Place the client's bed at the lowest height. A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room? A client who reports having fever, night sweats, and cough for 2 days. A hospice nurse is planning care for a client who has lung cancer. Which of the following statements should the nurse make to incorporate the client's and family's cultural beliefs? "We will respect what is important to you." A nurse is evaluating an older adult client who expresses concern about the aging process. Which of the following statements made by the client indicates a need for follow-up? "I guess feeling down is just part of aging." A client who has a terminal illness asks the nurse, "If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?" Which of the following statements should the nurse provide to explain a DNR prescription? A DNR prescription will allow you to continue with your current treatment regimen. A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium? 1 cup white rice A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? Limit family member visits to 30 min per day. A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion? Cool, clammy skin A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take? Instruct the client not to bend the affected leg. A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take? Clamp the tubing to check for air leaks. A nurse is assessing clients for skin integrity. Which of the following clients is at greatest risk for developing skin breakdown? A client who is paraplegic A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse expect? Pain occurs about 1 hr after eating A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider? "I am not very good about taking prescribed medication." A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations? Inability to exhale retained carbon dioxide A nurse is providing teaching about client rights to a client who has a brain tumor. Which of the following client statements indicates an understanding of the teaching? “I could refuse the treatment even after it has started." A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? "Take a hot shower to reduce pain in the morning." A nurse is preparing to administer intramuscular epinephrine to a client who is experiencing anaphylaxis. Which of the following sites should the nurse use? Vastus lateralis A nurse is providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include? Flush the toilet with the lid closed three times after use A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately? Pallor in the affected extremity A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take? Institute bleeding precautions. A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority? Respiratory Status A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of following statements by the client indicates an understanding of the teaching? "I will use canola oil when making salad dressing." A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? "I will check my pulse before I take the medication." A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make? "Use a raised toilet seat to maintain your hips above your knees." A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? Cloudy effluent A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe? Naloxone A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take. Place the cline in an upright sitting position Confirm that the client’s bladder is empty Administer an antihypertensive medication intravenously Indicate the risk for autonomic dysreflexia in the client’s medical record A nurse manager is providing an in-service to a group of newly licensed nurses about the use of personal protective equipment. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? "I should wear goggles when irrigating a wound." A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take? Pull the client up in bed. Presenting Complaint: Time of Onset: 0630 hours Symptoms: Client reports tightness in chest that radiates to left arm after eating breakfast. The pain was initially rated as 7/10 and reduced to 5/10 after treatment with nitroglycerin. Client also experienced nausea, diaphoresis, and shortness of breath. Heart rate was irregular and tachycardic. Medical History: Conditions: Hyperlipidemia , hypertension, type 2 diabetes mellitus. Lifestyle: Non-smoker. Denies use of alcohol or recreational drugs. The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up: Blood pressure Pain level Troponin T level Electrocardiogram findings Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again. Nurses' Notes 1000: Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds. Client reports tightness in chest that radiates to left arm States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast Client is diaphoretic and short of breath Heart rate irregular and tachycardic Presenting Complaint: Time of Onset: 0630 hours Symptoms: Client reports tightness in chest that radiates to left arm after eating breakfast. The pain was initially rated as 7/10 and reduced to 5/10 after treatment with nitroglycerin. Client also experienced nausea, diaphoresis, and shortness of breath. Heart rate was irregular and tachycardic. Medical History: Conditions: Hyperlipidemia , hypertension, type 2 diabetes mellitus. Lifestyle: Non-smoker. Denies use of alcohol or recreational drugs. Complete the following sentence by using the lists of options. The nurse should first address the client Select an option pain leveldiaphoresisnausea followed by the client's Select an option pulsesCholesterolECG results Dropdown Group 1: nausea Dropdown Group 2: Pedal pulses For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Pedal A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Anticipate client to be prepped for cardiac catheterization. Assist with a continuous heparin infusion. Obtain a prescription for client to be NPO. The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply. Blood pressure Pain level Heart rate Respiratory rate Oxygenation saturation Presenting Complaint: Time of Arrival: 0900 hours Symptoms: Client reports not feeling well for the past 12 hours, with increasing blood glucose levels. Client has a history of type 1 diabetes mellitus and hypertension. Recent treatment for bronchitis and pneumonia. Reports nausea, decreased appetite, frequent urination, and extreme thirst. Medical History: Conditions: Type 1 diabetes mellitus, hypertension. Recent Illnesses: Bronchitis, pneumonia. Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again. 1400: Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL) 1400: Temperature 36.8° C (98.2° F) Pulse rate 84/min Respiratory rate 16/min Blood pressure 106/76 mm Hg Oxygen saturation 96% on room air Client urinating 100 mL/hour Client is tolerating soft diet and oral fluids Bilateral pedal pulses 2+ Blood glucose 310 mg/dL (74 to 106 mg/dL) Pulse rate 84/min Respiratory rate 16/min Blood pressure 106/76 mm Hg Presenting Complaint: Time of Arrival: 0900 hours Symptoms: Client reports not feeling well for the past 12 hours, with increasing blood glucose levels. Client has a history of type 1 diabetes mellitus and hypertension. Recent treatment for bronchitis and pneumonia. Reports nausea, decreased appetite, frequent urination, and extreme thirst. Medical History: Conditions: Type 1 diabetes mellitus, hypertension. Recent Illnesses: Bronchitis, pneumonia. Complete the following sentence by using the lists of options. The nurse should administer a total sodium chloride in the first hour, each subsequent hour. Select an option Select an option 1320 mL1032 mL1230 mL 888 mL880 mL808 Ml The nurse should administer a total 1320ml sodium chloride in the first hour, 880ml each subsequent hour. The nurse should plan to first administer Dropdown Group 1: 0.9% sodium chloride Dropdown Group 2: Insulin Which of the following 3 provider prescriptions does the nurse anticipate? Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process. The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply. Cerebral edema Cardiac arrhythmias Renal failure Hypotension A nurse is reviewing the arterblood gas report of a client who is in metabolic acidosis. Which of the following findings should the nurse expect? pH 7.28 (7.35 to 7.45) A nurse is caring for a postoperative client who has an indwelling urinary catheter. Which of the following actions should the nurse take when removing the catheter? Place the client in the dorsal recumbent position A nurse in a provider's office is evaluating a client who has been taking lisinopril for hypertension. The nurse should identify which of the following findings as an adverse effect of this medication? Cough A nurse is teaching a client who has HIV about infection prevention. The nurse should instruct the client to avoid contact with which of the following items? Soiled cat litter A nurse is triaging clients following a mass casualty accident. Which of the following clients should be the nurse's priority? A client who has a metal bar protruding from the upper abdomen and is hyperventilating A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take? Monitor the client's calorie intake daily. A nurse on a medical-surgical unit is preparing to administer amoxicillin PO when the client refuses the medication. Which of the following actions should the nurse take? Record the client's refusal in the electronic health record. A nurse is teaching a client who has diabetes mellitus about home management of mild hypoglycemia. Which of the following statements should the nurse include in the teaching? "Retest your blood glucose 15 minutes after treatment of a hypoglycemic episode." A nurse is planning care for a client who has GERD and reports regurgitation after eating. Which of the following tests should the nurse anticipate the provider to prescribe for the client? Barium swallow A nurse is caring for a client who has COPD and reports dyspnea. In which of the following positions should the nurse place the client? Fowler's A nurse is obtaining a blood sample from a client's central venous access device. Which of the following actions should the nurse take? Cleanse the connections with povidone-iodine. A nurse is reviewing a client's ABG results and notes pH 7.3 (7.35 to 7.45), PaO2 81 mm Hg (80 to 100 mm Hg), PaCO2 50 mm Hg (35 to 45 mm Hg), and HCO, 26 mEq/L (21 to 28 mEq/L). Which of the following acid-base imbalances is the client experiencing? Respiratory acidosis A nurse in the PACU is caring for a client following a thyroidectomy. Which of the following findings should the nurse report to the provider? Dyspnea A nurse is preparing to administer a unit of packed RBCs to a female client who has a hemoglobin of 7.2 g/dL (12 to 16 g/dL). Which of the following actions should the nurse take? Review the medical record for type and crossmatch information. A home hospice nurse is caring for a client who has end-stage osteosarcoma and informs the nurse that they have been receiving acupuncture treatment to help with the pain. Which of the following responses should the nurse make? This can be part of your plan as long as your provider approves." A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have available? Protamine sulfate A nurse is providing discharge teaching to a client who has osteomyelitis in their left leg. Which of the following findings should the nurse identify as requiring a referral? The client has a WBC count of 20,000/mm3 (5,000 to 10,000/mm3). Client reports after eating breakfast this morning at 0630 that they began feeling tightness in chest that radiates to left arm. History: Hyperlipidemia, hypertension, type 2 diabetes mellitus. Non-smoker. Denies use of alcohol or recreational drug use. A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Select all that apply. Anticipate client to be prepped for cardiac catheterization. Assist with a continuous heparin infusion Obtain a prescription for client to be NPO The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply. Pain level Respiratory rate Heart rate Blood pressure Hypotension Cardiac arrhythmias Renal failure Cerebral edema Which of the following 3 provider prescriptions does the nurse anticipate? Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr Insert indwelling urinary catheter A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection? Make sure the client's room has positive-pressure airflow. A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make? "I can arrange for a social worker to talk with you before you leave." A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take? Request an interpreter during the initial assessment.