Nausea and indigestion. 650. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next? Observe the amount and dose of morphine in the PCA pump syringe. 651. A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete? Surgeon needs to see client immediately to evaluate the situation 652. Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome? Avoid exposure to respiratory infections 653. The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall (152 cm) and weighs 155 pounds (70 kg), the client’s 24 hour diet history includes: no breakfast, cheeseburger and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply) Avoid use of alcohol as a sleep aide at bedtime Start a weight loss program 654. A male client with impaired renal function who takes ibuprofen daily for chronic
arthritis…gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml / hour. Which intervention should the nurse include in hours? Evaluate daily serial renal laboratory studies for progressive elevations 655. The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris…to the health care provider before administering this medication? Irregular pulse 656. When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform? Hold the thermometer in place. 657. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive…medication therapy, the nurse notices the client has more energy, is giving her belongings…mood. Which intervention is best for the nurse to implement? Ask the client if she has had any recent thoughts of harming herself 658.
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- Fall '19
- Nursing, UAP, male client