A goal of care for a client with congestive heart failure (CHF)is for serum sodium levels to be within normal limits.Which information documented in the medical record would indicate that the client is not meeting this goal?
A novice nurse is planning care for an older adult client with a wound infection and systemic blood infection.The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking?
A client with congestive heart failure (CHF)is having difficulty breathing.Before leaving the room,the nurse ensures the client has an overbed table to lean on when awake if needed to ease breathing.Which technique did the nurse use to make this decision?
The nurse is assigned two clients.One client needs postoperative teaching in preparation for discharge,and the other client with pneumonia has a PaCO2 of 85.Why does the nurse decide to see the client with pneumonia first?
An older adult client is experiencing confusion,a temperature of 101.5°F,bruising to the arms and legs,and decreased urine output.The medical diagnosis is a urinary tract infection.Which is the most appropriate nursing diagnosis for this client?
The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery.The client has lost 10 pounds,is continuing to experience pain,and is not eating.What should be the nurse's next action?
A client begins to vomit blood.The nurse immediately measures the blood pressure and prepares to insert a nasogastric tube while directing others to notify the healthcare provider and prepare to perform iced saline lavage.Which features of the Tanner Clinical Judgment Model did this nurse demonstrate? Select all that apply.
A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours.At 4 hours the client's pain level is 8 on a rating scale of 1 to 10.The nurse decides to give the pain medication now.What does this nurse's action exemplify?
The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died.On which areas should the nurse focus when performing this reflection? Select all that apply.
The nurse is caring for an older adult client with decreased energy who needs to get up to prevent the development of pressure ulcers.The client is unable to ambulate and wants to be alone.What should the nurse do?
The urgent care clinic nurse is treating a client who is experiencing abdominal pain.The client states,"I think I ate tainted food last night." What should the nurse do after the client states that the food was tainted?
The nurse is caring for an older school-age client who is sleeping when the menu choices for dinner are brought to the room.Which intervention should the nurse use to meet the dietary needs of this client?