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Author Archives: Anonymous

A postoperative client is difficult to arouse and has respir…

A postoperative client is difficult to arouse and has respirations of 7/min. ABG results are pH 7.26 and PaCO₂ 58 mm Hg. Which action should the nurse take first?

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A client has new dyspnea, SpO₂ 88%, accessory-muscle use, an…

A client has new dyspnea, SpO₂ 88%, accessory-muscle use, and restlessness. How should the nurse interpret this cue cluster?

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A client develops rapid breathing, dizziness, and perioral t…

A client develops rapid breathing, dizziness, and perioral tingling. ABG results are pH 7.53, PaCO₂ 28 mm Hg, and HCO₃⁻ 23 mEq/L. How should the nurse interpret this cue cluster?

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A client reports burning with urination, urinary frequency,…

A client reports burning with urination, urinary frequency, urgency, and suprapubic discomfort. Temperature is 37.1°C (98.8°F), and the client denies flank pain. Which explanation best connects the clinical findings?

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A client with long-standing diabetes denies vision changes,…

A client with long-standing diabetes denies vision changes, numbness, chest discomfort, and urinary symptoms. Serum creatinine is within the expected range, foot skin is intact, and the client has not had urine albumin testing, a dilated retinal examination, or protective-sensation testing during the past year. Which explanation best connects the clinical findings?

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A postoperative client has produced 75 mL of urine over 6 ho…

A postoperative client has produced 75 mL of urine over 6 hours. The client reports lower-abdominal pressure, and a bladder scan shows 640 mL. Which explanation should the nurse prioritize?

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A client reports urinary burning and constant left flank dis…

A client reports urinary burning and constant left flank discomfort. Temperature is 39.0°C (102.2°F), heart rate is 112/min, and blood pressure has decreased from 126/74 to 98/60 mm Hg. Left costovertebral-angle tenderness is present. The client denies colicky pain and visible blood in the urine. Which explanation best connects the clinical findings?

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A client has severe flank pain that comes in waves and radia…

A client has severe flank pain that comes in waves and radiates toward the groin. The client is restless and nauseated, and urinalysis shows microscopic blood without nitrites. Which explanation best connects the clinical findings?

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Two hours after receiving rapid-acting insulin, a client’s m…

Two hours after receiving rapid-acting insulin, a client’s meal has not arrived. During reassessment, the client asks when breakfast will arrive, reports hunger, has a damp gown and visibly shaking hands, and gives newly incorrect answers to orientation questions. Which observation requires immediate follow-up?

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A client with type 2 diabetes is scheduled to receive metfor…

A client with type 2 diabetes is scheduled to receive metformin. The client has had vomiting and poor intake for 24 hours, serum creatinine has increased from 0.9 to 1.8 mg/dL, and a contrast-enhanced CT is scheduled this morning. Which action should the nurse take?

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