While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be
... [Show More] pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
Perform a bedside pregnancy test.
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?
Hematuria
The nurse is providing teaching to a client with type 2 diabetes mellitus about managing care at home. Which information provided by the client indicates understanding?
Include no more than 1-2 alcoholic beverages in diet per day
A client is recovering from a transurethral prostatectomy. Which activity should we limited until the first postoperative visit with his health care provider?
Driving in a car.
The home health nurse provides teaching about insulin self injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video which instruction should the nurse provide?
Continue with the insulin injection
The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son who is human immunodeficiency virus (HIV) positive. Which symptom confirms their suspicious?
A change has recently occurred in his handwriting
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signals, heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement?
Encourage the client to splint the incision with a pillow to cough and deep breathe
After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without reflux. Her vital signs are heart rate 122 beats/minute, respiration 16 breaths/minute, oxygen saturation 96% and blood pressure 116/70 mmHg. The nurse obtains a 12 lead electrocardiogram. Which assessment finding is most critical?
ST elevation in three leads
A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?
Distended, hard, and rigid abdomen
A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the clients plan of care?
Begin straining all urine
. A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the clients blood pressure drops mmHg to 80/30 mmHg. Which action should the nurse take first?
Lower the head of the chair and elevate feet
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
Eating patterns of dietary intake
A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?
Profuse diaphoresis and severe, pounding headache [Show Less]