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Case Summary A 69-year-old male client is admitted to the medical-surgical unit for an evaluation of pain and edema of the right lower extremity. The onset of symptoms was 2 days prior to arrival. Client is diagnosed with a deep vein thrombosis requiring heparin therapy. The nurse on the medical-surgical unit is caring for a 69-year-old male client with pain and swelling of the right lower extremity.   Nurses’ Notes     Day 1. 0930 Admission note: Client admitted from the Emergency Department via stretcher and transferred to bed. Client is alert and oriented. Saline lock IV in the R antecubital vein patent. Right lower extremity noted to have 2+ pedal edema, pain 8/10 in right calf. Warmth noted to right calf. Positive Homan’s sign to R lower extremity noted. Client has positive motion and sensation to right lower extremity. Right pedal pulse weak, palpable. R lower extremity elevated on 2 pillows.  VS: BP 145/82, HR 96, RR 16, Temp 36.7C (98F). Client ordered to be on complete bedrest. Client made aware. 1010: Radiology called results of right leg ultrasound: Positive for deep vein thrombosis of the right posterior tibial vein. Provider made aware. New orders pending.   Nurses’ notes have been updated with most recent radiology results. Based on the above scenario, which interventions would be implemented for this patient’s plan of care?

Priority nursing actions for a hospitalized client with a new-onset temperature of 102.2°{“version”:”1.1″,”math”:”°”}F and severe neutropenia include which of the following? Select all that apply.

What is the primary collaborative goal of a client with lymphedema and resultant fluid volume excess?

A client had a repair of an abdominal aneurysm 2 days ago. Which of the following will the nurse report immediately to the health care provider?

The nurse is teaching the client with Meniere’s disease about controlling symptoms through diet. Which of the following will the nurse emphasize? Select all that apply.

Which of the following clients is most at risk for developing thrombophlebitis?

Which intervention will be most effective in preventing thrombophlebitis in the post-operative client?

The client is to receive a 100mL antibiotic over 30 minutes via an intravenous (IV) pump. At what rate will the nurse set the IV pump? Please record your answer as a whole number.

During an acute phase of Guillian-Barre´ Syndrome, what is the priority nursing assessment?

The nurse conducts a home visit on 68-year-old male client with Parkinson’s disease following a recent fall 3 days after discharge from an acute care setting. Nurses’ Notes     1000 – Initial post-discharge visit in the client’s home. Met with client and his son. The client has moderate stage Parkinson’s disease and lives with his adult son, who works full-time and provides supportive care. Client reports that he fell on the stairs, attempting to use the second-floor bathroom. Assessment findings: Client is alert and oriented to person, place and time Walks short distances using a walker without problem, but reports that he tires easily Resting tremors noted in both arms and legs Son reports client needs assistance with ADLs on days when rigidity is worse Client reports that he has not slept more than 2 hours per night since discharge   1100 – After a short rest, continued assessment. Blood pressure sitting 138/88, standing 116/60, complains of dizziness on standing Heart rate 86 beats per minute and regular Respirations 16 per minute and unlabored; breath sounds clear bilaterally Temperature 97.2F (36.2C) Strength in legs is diminished bilaterally, but client is able to bear weight using walker Range of motion is within normal limits but rigid in all extremities Client reports frequent urination, “I am sometimes unable to make it to the bathroom” Speech is slow and halted, but understandable Moderate, continuous drooling noted Medications     Lisinopril 40 mg by mouth once daily for hypertension Carbidopa/levodopa 12.5 mg/50 mg 3 times daily by mouth to treat Parkinson’s symptoms   Select the risk factors for this patient when performing a fall risk assessment. Select all that apply