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A hospitalized 68-year-old client has a biventricular pacemaker placed in the right subclavicular area. The nurse is providing care following the procedure and is initiating postprocedure teaching. Which findings following postprocedure assessment and teaching are unexpected and therefore require additional follow-up? Select all that apply.

A nurse is assessing a patient with suspected Acute Respiratory Distress Syndrome (ARDS). Which clinical finding is most indicative of ARDS? 

A nurse is collecting the medical history from a patient who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the patient if he has a history of which of the following conditions that can cause SIADH?

A nurse is caring for an ICU patient experiencing anaphylactic shock after receiving an antibiotic. The patient’s current vital signs are T 99.3, RR, 22, O2 95% on room air, HR 122, BP 98/54. Which intervention should the nurse prioritize first? 

An emergency department triage nurse is evaluating a patient reporting general malaise. The assessment reveals jaundice and increased abdominal girth. Which question would best help determine the cause of the patient’s symptoms? 

The nurse is teaching the patient about open-heart surgery. Which of the following items is NOT part of the teaching plan?

A nurse is assessing a patient newly diagnosed with HIV. Which symptom is most commonly reported during the acute stage (stage I) of HIV infection? 

When assessing a 22-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for:

Case Study: The nurse is preparing a 68-year-old client in a rehabilitation center for discharge to home. The client was transferred from the hospital 2 weeks ago following treatment for a right cerebral stroke. On admission to the rehabilitation center, the following findings were documented. Nurses Notes Vital Signs Physician’s Orders Client is accompanied by spouse, who will be the primary caregiver when the client returns home.Alert and oriented and understands about receiving rehabilitative therapy before returning to home. States doesn’t really have “much to rehab” and is fine but will do what the doctor says to get home. Has left-side weakness and seems impulsive with movements. Able to move right arm and leg with adequate strength noted.Has difficulty focusing and attention span is short; spouse is assisting in answering questions.Spouse notes that the client’s judgment is impaired and is concerned about the client’s safety because of the client’s impulsivity.Client also exhibits left-sided neglect; lacks proprioception.Has homonymous hemianopsia. T = 98.6°F  HR = 92 BPM BP 132/78 RR = 20 bpm SpO2 = 95% on RA PT and OT evaluation and initiate a treatment plan as neededLow-fat dietOut of bed as much as toleratedBegin to prepare client and spouse for discharge to homeReferral to case manager to plan dischargeClopidogrel 75 mg oral dailyCarvedilol 3.125 mg oral twice dailyDocusate 100 mg oral dailySimvastatin 20 mg oral daily Which client or spouse statement/observation indicates that the home care instruction is either understood or requires further teaching? Spouse states: “It will help vision if I approach my spouse from the right side.”: [statement1] Client turns the head to the right and then to the left before taking on an activity.: [statement2] Client states: “I know that I need to call for help if I need to use the bathroom.”: [statement3]  

The nurse is completing discharge education with a patient who underwent a mechanical heart valve replacement. Which of the following statements by the client indicates understanding of the teaching?