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A nurse is caring for a client who has a history of angina. Nurses’ Note Vital Signs 1000: Client is awake, alert, and oriented to person, time, and place. Bilateral breath sounds clear and present throughout. Apical pulse regular.      1200: Client reports chest tightness radiating to jaw, not relieved with rest, and periods of nausea, dizziness, and palpitations.     Client is diaphoretic and appears anxious. Bilateral breath sounds clear and present throughout. Apical pulse irregular and rapid.   1000: Temperature 37.5° C (99.5° F) BP 150/80 mm Hg Heart rate 90/min Respirations 20/min Pulse oximetry 97% on room air   1200: Temperature 37.5° C (99.5° F BP 180/86 mm Hg Heart rate 112/min Respirations 24/min Pulse oximetry 95% on room air Which of the following findings require follow-up by the nurse? Select all that apply.

The nurse has been assigned a 54 year old patient, C.T., who has been brought into the emergency department by a daughter because of sudden weakness and a decreasing level of consciousness. The daughter says that C.T. has been reporting nausea, with associated abdominal and back pain, and usually C.T.  is very alert and oriented, but today is increasingly lethargic.  The nurse reviews the chart below. Medical History Initial Vital Signs Hypertension Atrial Fibrillation Diabetes Mellitus Type 2 Blood Pressure: 102/38 mm Hg Heart Rate: 102 beats/min O2 saturation: 76% Respiratory Rate: 30 breaths/min Temperature: 102.4 F  The health care provider writes orders for C.T and the nurse determines which order to is the priority to implement first?

A client with acute infective endocarditis suddenly complains of shortness of breath and chest pain. Upon assessment, the nurse notes diminished breath sounds and hemoptysis. Which situation does the nurse suspect?   

Clinical Scenario: Mick Alfons, a 72-year-old male with a history of aortic stenosis, presents to the clinic with complaints of increasing shortness of breath, fatigue, and chest pain on exertion. He has been experiencing these symptoms for the past few months, and they have progressively worsened. On examination, he has a systolic murmur heard best at the right second intercostal space. His blood pressure is 150/90 mmHg, and his heart rate is 88 bpm. The nurse suspects that has [condition] related to [cue1] and [cue2]  

The nurse is caring for a client on postop day one (1) following coronary artery bypass grafting and notes the client’s cardiac rhythm to be sinus tachycardia. Which action should the nurse do first?    

A patient is being discharged 4 days following surgery for coronary artery bypass grafting (CABG). The nurse knows the patient understands the discharge teaching when the patient states what?

If you provide feedback every 5th trial, what is your feedback schedule?

A 7-year-old has reached 90% accuracy with /l/ in sentences during pull-out therapy. However, the teacher reports the child still says “wamp” for “lamp” during classroom reading. Which strategy best addresses this generalization gap?

Auditory Discrimination must be 100% perfect before a child can begin motor production.

A child who says “tea” for “key” and “tate” for “cake” (Fronting) would benefit most from: