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While completing your patient’s physical assessment, you notice cola-colored urine in your patient’s urinary catheter (Foley) bag.  Your patient also describes discomfort in their bilateral lower extremities (calves) when completing the musculoskeletal assessment.  You review your patient’s Medication administration record (MAR).  Which medication do you anticipate your patient is currently taking based on these findings?

A client’s most recent laboratory results show a slight decrease in potassium. The health care provider has opted to forgo drug therapy but has suggested increasing the client’s dietary intake of potassium. What should the nurse recommend?

The nurse is caring for a client with a diagnosis of pancreatitis. The client was admitted from a homeless shelter and is a vague historian. The client appears malnourished and on day 3 of the client’s admission, total parenteral nutrition (TPN) has been started. Why should the nurse start the infusion of TPN slowly?

A nurse is caring for a client with acute renal failure and hypernatremia.  In this case, which action can be delegated to the nursing assistant?

The intensive care unit nurse is caring for a client who experienced trauma in a workplace accident. The client is reporting dyspnea because of abdominal pain. An arterial blood gas test reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3– 20 mEq/L. The nurse should recognize the likelihood of which acid–base disorder(s)?

The nurse caring for a 79-year-old patient who has just returned to the medical–surgical unit following surgery for a total knee replacement received report from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that the patient has been agitated in the past following opioid administration. What principle(s) should guide the nurse’s management of the patient’s pain? Select all that apply.

A 52-year-old patient is receiving care on the oncology unit for breast cancer that has metastasized to the lungs and liver. When addressing the patient’s pain in the plan of nursing care, the nurse should consider what characteristic of cancer pain?

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. Which factors contribute to this phenomenon? Select all that apply.

The nurse assesses the pain of a patient with cholelithiasis. The patient is tearful, hesitant to move, grimacing, and rates pain as a 2 at this time using a 0-to-10 pain scale. Which is the best action by the nurse in response to this assessment finding? 

An emergency department nurse is caring for a trauma patient with arterial blood gas (ABG) results of pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would the nurse interpret these results?