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Part 2 of 3: “Action to Take”   DATE TIME NURSES’ NOTES March 1, 2023 0820 Client Ms. Lewis is 21-year-old female with blood glucose of 864 mg/dL and serum potassium level of 2.9 mEq/L reports abdominal pain, headache, fatigue, frequent urination, excessive thirst, has rapid deep breathing and fruity sweet-smelling breath.  The nurse is reviewing the client’s assessment data to prepare the client’s plan of care. Identify what TWO actions the nurse should take FIRST.

The nurse is caring for four patients in the emergency department. Review the information provided for each patient and prioritize them based on their condition. Which patient needs to be seen first?

Pregestational diabetes (DM1 or DM2) places the fetus at risk in several ways.  Nurses should be aware that:

A woman experiencing severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the client and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats per minute, respiratory rate of 24 breaths per minute, BP of 155/112 mm Hg, 3+ DTRs, and no ankle clonus. The nurse calls the provider with an update. The nurse should anticipate an order for which medication?

Mrs. Jacobson, a 40-year-old, presents with complaints of persistent vomiting for the past 24 hours. The nurse observes signs of dehydration and metabolic disturbances. Which condition is a potential risk factor for the acid-base imbalance observed in this patient?

When evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, the fingers fan out and form a “C” with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive:

Which factors can contribute to an increased risk of neonatal jaundice? Choose all that apply.

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand.  Nurses should know that:

Advantages of using informatics in health care delivery are: (Select all that apply)

An adult female with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms?