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The nurse is beginning the shift and assigned the following clients. Which client will the nurse assess first?

A client with unstable angina is receiving an IV Heparin Infusion and an IV Eptifibatide infusion. Which of the following lab results is most important for the nurse to report to the health care provider to prevent an adverse medication effect?

The client is placed on furosemide for hypertension. How would the nurse assess the effectiveness of the medication?

A client arrives at the emergency department with increasing shortness of breath, productive cough, and wheezing for the past 3 days.  Past Medical History Chronic obstructive pulmonary disease (COPD) – diagnosed 10 years ago, Hypertension, Hyperlipidemia, Former smoker: 40 pack-years, quit 2 years ago   Current Medications Tiotropium inhaler once daily Albuterol MDI as needed Lisinopril 10 mg daily Atorvastatin 20 mg nightly   Assessment Vitals: 100.6 *F, 112 bpm, 28/min labored, 152/88 mmHg, 86% on room air Client is ALOx3. Client has diminished breath sounds with expiratory wheezing and accessory muscle use, prolonged expiratory phase. Productive cough with thick, green sputum. Heart rate 112bpm, regular rhythm.  Bowel sounds present in all four quadrants. Voiding concentrated yellow urine with no complaints of pain. Skin clean, dry, and intact. Clubbing of fingernails present. 20G peripheral IV inserted into the right antecubital.  Laboratory and Diagnostic Test Results ABGs Results Reference pH 7.31 7.35-7.45 PaCO2 58 35-45 mmHg HCO3 30 22-26 mEq/L PaO2 55 75-100 mmHg     CXR: hyperinflation, no focal consolidation CBC Results Reference White blood cells 14.5 4000-11000/mcL Red blood cells 5.8 million/mcL 4.7-6.1 million/mcL Hemoglobin 13.1 g/dL 13.2-16.6 g/dL Hematocrit 38% 38.3-48.6% Platelets 152 150-400 K/uL Which problem should the nurse prioritize for this client?

A client in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site located in the femoral region. What is the nurse’s most appropriate action?

A client arrived in the emergency department after being involved in a motor vehicle accident. He exhibits a complete loss of motor, sensory, and reflex activity below the level of injury, concurrent hypotension, and bradycardia. The nurse should collect what additional data to determine if the client is experiencing spinal shock?

What is the expected outcome following therapeutic response to Phytonadione, a vitamin K injection? 

A client is admitted to the hospital after experiencing retrosternal chest pain that radiates down the left arm. When obtaining a pain assessment, which question is most relevant?

A nurse is caring for a client with a seizure disorder and has stopped taking their prescribed pregabalin due to weight gain. Which of the following findings should the nurse recognize as withdrawal symptoms from pregabalin? 

A client arrives at the emergency department with increasing shortness of breath, productive cough, and wheezing for the past 3 days.  Past Medical History Chronic obstructive pulmonary disease (COPD) – diagnosed 10 years ago, Hypertension, Hyperlipidemia, Former smoker: 40 pack-years, quit 2 years ago   Current Medications Tiotropium inhaler once daily Albuterol MDI as needed Lisinopril 10 mg daily Atorvastatin 20 mg nightly   Assessment Vitals: 100.6 *F, 112 bpm, 28/min labored, 152/88 mmHg, 86% on room air Client is ALOx3. Client has diminished breath sounds with expiratory wheezing and accessory muscle use, prolonged expiratory phase. Productive cough with thick, green sputum. Heart rate 112bpm, regular rhythm.  Bowel sounds present in all four quadrants. Voiding concentrated yellow urine with no complaints of pain. Skin clean, dry, and intact. Clubbing of fingernails present. 20G peripheral IV inserted into the right antecubital.  Laboratory and Diagnostic Test Results ABGs Results Reference pH 7.31 7.35-7.45 PaCO2 58 35-45 mmHg HCO3 30 22-26 mEq/L PaO2 55 75-100 mmHg     CXR: hyperinflation, no focal consolidation CBC Results Reference White blood cells 14.5 4000-11000/mcL Red blood cells 5.8 million/mcL 4.7-6.1 million/mcL Hemoglobin 13.1 g/dL 13.2-16.6 g/dL Hematocrit 38% 38.3-48.6% Platelets 152 150-400 K/uL Which nursing intervention is most appropriate during oxygen administration?