Author: Anonymous

The client is placed on furosemide for hypertension. How would the nurse assess the effectiveness of the medication?

A client arrives at the emergency department with increasing shortness of breath, productive cough, and wheezing for the past 3 days.  Past Medical History Chronic obstructive pulmonary disease (COPD) – diagnosed 10 years ago, Hypertension, Hyperlipidemia, Former smoker: 40 pack-years, quit 2 years ago   Current Medications Tiotropium inhaler once daily Albuterol MDI as needed Lisinopril 10 mg daily Atorvastatin 20 mg nightly   Assessment Vitals: 100.6 *F, 112 bpm, 28/min labored, 152/88 mmHg, 86% on room air Client is ALOx3. Client has diminished breath sounds with expiratory wheezing and accessory muscle use, prolonged expiratory phase. Productive cough with thick, green sputum. Heart rate 112bpm, regular rhythm.  Bowel sounds present in all four quadrants. Voiding concentrated yellow urine with no complaints of pain. Skin clean, dry, and intact. Clubbing of fingernails present. 20G peripheral IV inserted into the right antecubital.  Laboratory and Diagnostic Test Results ABGs Results Reference pH 7.31 7.35-7.45 PaCO2 58 35-45 mmHg HCO3 30 22-26 mEq/L PaO2 55 75-100 mmHg     CXR: hyperinflation, no focal consolidation CBC Results Reference White blood cells 14.5 4000-11000/mcL Red blood cells 5.8 million/mcL 4.7-6.1 million/mcL Hemoglobin 13.1 g/dL 13.2-16.6 g/dL Hematocrit 38% 38.3-48.6% Platelets 152 150-400 K/uL Which problem should the nurse prioritize for this client?

A client in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site located in the femoral region. What is the nurse’s most appropriate action?

A client arrived in the emergency department after being involved in a motor vehicle accident. He exhibits a complete loss of motor, sensory, and reflex activity below the level of injury, concurrent hypotension, and bradycardia. The nurse should collect what additional data to determine if the client is experiencing spinal shock?

What is the expected outcome following therapeutic response to Phytonadione, a vitamin K injection? 

A client is admitted to the hospital after experiencing retrosternal chest pain that radiates down the left arm. When obtaining a pain assessment, which question is most relevant?

A nurse is caring for a client with a seizure disorder and has stopped taking their prescribed pregabalin due to weight gain. Which of the following findings should the nurse recognize as withdrawal symptoms from pregabalin? 

A client arrives at the emergency department with increasing shortness of breath, productive cough, and wheezing for the past 3 days.  Past Medical History Chronic obstructive pulmonary disease (COPD) – diagnosed 10 years ago, Hypertension, Hyperlipidemia, Former smoker: 40 pack-years, quit 2 years ago   Current Medications Tiotropium inhaler once daily Albuterol MDI as needed Lisinopril 10 mg daily Atorvastatin 20 mg nightly   Assessment Vitals: 100.6 *F, 112 bpm, 28/min labored, 152/88 mmHg, 86% on room air Client is ALOx3. Client has diminished breath sounds with expiratory wheezing and accessory muscle use, prolonged expiratory phase. Productive cough with thick, green sputum. Heart rate 112bpm, regular rhythm.  Bowel sounds present in all four quadrants. Voiding concentrated yellow urine with no complaints of pain. Skin clean, dry, and intact. Clubbing of fingernails present. 20G peripheral IV inserted into the right antecubital.  Laboratory and Diagnostic Test Results ABGs Results Reference pH 7.31 7.35-7.45 PaCO2 58 35-45 mmHg HCO3 30 22-26 mEq/L PaO2 55 75-100 mmHg     CXR: hyperinflation, no focal consolidation CBC Results Reference White blood cells 14.5 4000-11000/mcL Red blood cells 5.8 million/mcL 4.7-6.1 million/mcL Hemoglobin 13.1 g/dL 13.2-16.6 g/dL Hematocrit 38% 38.3-48.6% Platelets 152 150-400 K/uL Which nursing intervention is most appropriate during oxygen administration?

A nurse in a primary care setting is assessing a client with possible tuberculosis. The nurse should identify that which findings are manifestations of pulmonary tuberculosis? Select all that apply

A 62 y/o male is arriving via Emergency Medical Services (EMS) with chest pain.   Nurse’s Note:  12/16/20xx 1010: 62 y/o male c/o crushing sternal pain, radiating down the left arm. States the pain becomes worse with activity and started approximately two hours ago while shoveling snow. Patient states he is also short of breath with activity. Pt is ALOx3. Lungs clear throughout. Abd soft, nontender, bowel sounds active. Pt states urinary output is “normal” with no c/o of odor, pain, pressure. Skin is C/D/I. 18G in the left forearm.      Vital Signs:  98.4 F, HR – 99, RR – 18, BP 162/89, Pulse Ox: 93% on RA  ECG:  Sinus Tachycardia rate 99 bpm. ST elevation noted in V3 and V4  Laboratory Results:  Lab  Results  Reference Range:  WBC  9 x 10^3 cells/mm3  4500–11,000/mm3  RBC  5.3 × 106/μL  4.7-6.1 × 106/μL  Hgb  15.8 g/dL  Male: 14–17.4 g/dL  Hct  44%  Male: 42–52%  Plts  254,000/mm3  140,000–400,000/mm3  Na  144 mEq/L  135-147 mEq/L  Cl  104 mEq/L  95-106 mEq/L  K  4.8 mEq/L  3.5-5.3 mEq/L  CO2  29 mEq/L  22-30 mEq/L  BUN  12 mg/dL  6-20 mg/dL  Cr  1.1 mg/dL  0.6-1.3 mg/dL  Troponin T  0.7 ng/mL  0-0.04 ng/mL  Creatine Kinase MB (CK-MB)  187 IU/L  5-25 IU/L  Cholesterol  265 mg/dL  240 high  The nurse completes the following H&P: H&P:  62 y/o male lives independently at home with spouse of 40 years. Came in on 12/16/23 after shoveling snow c/o crushing sternal pain, radiating down the left arm. States he stopped shoveling after 30mins of pain, and the pain continued. The pain becomes worse with activity and started approximately two hours ago. Patient states he also became short of breath with activity.   Wt: 102.3 kgs  Ht: 5’9”  BMI: 33.2  PMH: DMII, HLD, GERD, Asthma, Sleep apnea, Smoker 1/2 pack per day  Family Hx:  Mother – Alive – DMII, CAD, CHF, COPD  Father – Deceased at 52 – MI, CAD  Sibling – Alive – CAD, DMII   Diet: High in carbohydrates, protein; poor in fresh fruits/vegetables.   Occupation: Owns own business – landscaping   The physician orders the following stat. Specify whether the order is indicated or not indicated for this patient’s plan of care.