The nurse is caring for a client who is exhibiting signs and…
The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In additions to normal saline, which crystalloid fluid should the nurse prepare to administer?
Read DetailsYou are caring for an 80-year old client with a cerebrovascu…
You are caring for an 80-year old client with a cerebrovascular accident that has caused right-sided paralysis. The IV in her left arm is infiltrated. You are going to have to restart the IV. Where will the new IV site be located?
Read DetailsA 74-year old female is admitted to the Emergency room with…
A 74-year old female is admitted to the Emergency room with increasing dyspnea, productive cough, and fatigue. Nurses’ Notes 1000: Client arrives in Emergency Department with worsening shortness of breath over the past week, strong productive cough with green-tinged sputum, and fatigue. Client has a history of chronic obstructive pulmonary disease -emphysema; has been using their “relief” inhaler at home with no relief of symptoms. Client lives independently at home and states they smoke approximately 1 pack of cigarettes per day. Ambulatory, alert and oriented x 4. Has coarse crackles auscultated in bilateral lower lung fields with a barrel chest appearance, using accessory muscles, expiratory wheeze on auscultation. Client states they have “less room” to take a deep breath. Clubbing noted in all digits bilaterally. 1015: Client has increasing dyspnea, prefers to be sitting up in the chair. Requesting “rescue inhaler.” The provider has been notified. IV started. Ipratropium bromide and albuterol nebulizer treatment started. Vital Signs Time 1000 1015 Oral Temp 99.0 F (37.2 C 99.0 F (37.2 C Pulse 104 108 Respiratory Rate 27 30 Blood Pressure 157/86 159/88 Pulse oximeter 91% room air 90% room air Pain 0 0 Provider ordered Medications (ER): Medication Dosage/Frequency/ Route Ipratropium bromide and albuterol 3mL(0.5mg ipratropium bromide 2.5 mg albuterol) nebulizer treatment 4 x a day. First dose now. Acetaminophen 500 mg x 1 PO PRN for moderate to severe back pain Methylprednisolone sodium succinate 40 mg IV push x 1 dose now Amoxicillin/clavulanate 875 mg/ 125 mg PO every 12 hours Albuterol sulfate 2.5 mg/3 ml nebulizer every 4 hours PRN Which medication do you anticipate that the nurse will give first?
Read DetailsAfter abdominal surgery, the client experiences a decrease i…
After abdominal surgery, the client experiences a decrease in blood pressure, decreased level of consciousness, abdominal distention, and a decreased urinary output. After calling the HCP (Health Care Provider), which order has the highest priority?
Read DetailsA client who is being treated for pneumonia reports sudden s…
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. Which condition does the ABG reflect?
Read DetailsThe nurse is caring for a client admitted to the medical uni…
The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube was placed upon admission, and since that time the client has been on low intermittent suction. Upon review of the morning’s blood work, the nurse notices that the client’s potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance?
Read DetailsA client was stabbed in the anterior chest with a steak knif…
A client was stabbed in the anterior chest with a steak knife. The nurse observes that the client’s airway is patent, that there is a 2-cm laceration on his anterior chest; a sucking noise is coming from his chest wound. What is the priority action?
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