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The nurse is performing an admission assessment on a 79-year-old client newly admitted for end-stage liver disease. What principle should guide the nurse’s assessment of the client’s skin turgor?

Harriet, 30 years old, has been admitted to the burn treatment center with full-thickness burns over 30% of her upper body. Her diagnosis is consistent with extracellular fluid volume deficit.  What symptoms would indicate to the nurse that the patient may be experiencing fluid volume deficit.  (Select all that apply)

You are the nurse caring for a trauma patient who presents to the ER following an automobile accident. The primary care provider prescribes the nurse to start an IV with a large bore needle to infuse fluids rapidly. What gauge catheter is the best choice for this situation?

A 74-year old female is admitted to the Emergency room with increasing dyspnea, productive cough, and fatigue.   Nurses’ Notes       1000: Client arrives in Emergency Department with worsening shortness of breath over the past week, strong productive cough with green-tinged sputum, and fatigue. Client has a history of  chronic obstructive pulmonary disease -emphysema; has been using their “relief” inhaler at home with no relief of symptoms. Client lives independently at home and states they smoke approximately 1 pack of cigarettes per day. Ambulatory, alert and oriented x 4. Has coarse crackles auscultated in bilateral lower lung fields with a barrel chest appearance, using accessory muscles, expiratory wheeze on auscultation. Client states they have “less room” to take a deep breath. Clubbing noted in all digits bilaterally.   1015: Client has increasing dyspnea, prefers to be sitting up in the chair. Requesting “rescue inhaler.” The provider has been notified. IV started. Ipratropium bromide and albuterol nebulizer treatment started.   Vital Signs       Time  1000 1015   Oral Temp  99.0 F (37.2 C 99.0 F (37.2 C   Pulse 104 108   Respiratory Rate 27 30   Blood Pressure 157/86 159/88   Pulse oximeter  91% room air 90% room air   Pain  0 0     Provider ordered Medications (ER):     Medication Dosage/Frequency/ Route   Ipratropium bromide and albuterol  3mL(0.5mg ipratropium bromide 2.5 mg albuterol) nebulizer treatment 4 x a day. First dose now.   Acetaminophen 500 mg x 1 PO  PRN for moderate to severe back pain   Methylprednisolone sodium succinate 40 mg IV push x 1 dose now   Amoxicillin/clavulanate  875 mg/ 125 mg PO every 12 hours   Albuterol sulfate 2.5 mg/3 ml nebulizer every 4 hours PRN Which medication do you anticipate that the nurse will give first?

After 2 months of tuberculosis (TB) treatment with isoniazide (INH) and rifampin (Rifadin), pyrazinamide (PZA) and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action will the nurse take next?

The nurse is administering a purified protein derivative (PPD) test on a nursing home resident. Which statements about this test are correct? Select all that apply. 

A 74-year-old female is admitted to the Emergency Room with increasing dyspnea, productive cough, and fatigue.   Nurses’ Notes       1000: Client arrives in Emergency Department with worsening shortness of breath over the past week, strong productive cough with green-tinged sputum, and fatigue. Client has a history of  chronic obstructive pulmonary disease -emphysema; has been using their “relief” inhaler at home with no relief of symptoms. Client lives independently at home and states they smoke approximately 1 pack of cigarettes per day. Ambulatory, alert and oriented x 4. Has coarse crackles auscultated in bilateral lower lung fields with a barrel chest appearance, using accessory muscles, expiratory wheeze on auscultation. Client states they have “less room” to take a deep breath. Clubbing noted in all digits bilaterally. Vital Signs       Time  1000   Oral Temp  99.0 F (37.2C)   Pulse 104   Respiratory Rate 27   Blood Pressure 157/86   Pulse oximeter  91% Room air   Pain  0   The nurse reviews the client’s initial assessment. Which priority findings require immediate follow-up? SELECT ALL THAT APPLY.

A client has a tracheostomy placed due to chronic respiratory failure. Upon return to the unit, the nurse notes that the outer cannula has been coughed from the trachea. What is the nurse’s priority action?

On auscultation of patient’s lungs, the nurse hears high pitched musical noise on inspiration. How will the nurse document this finding?

A client at the clinic is diagnosed with tuberculosis. When developing this client’s plan of care, which medications will the nurse anticipate as being prescribed as a first-line agent? Select all that apply.