A patient with a fractured pelvis is initially treated with bed rest and no turning from side to side permitted.  The second day after admission, the patient develops chest pain, tachypnea, and tachycardia.  The nurse determines that the patient’s symptoms are most likely related to fat embolism when assessment of the patient reveals;

An 82-year-old woman with a history of chronic heart failure is in the Emergency Department with increased dyspnea, extreme fatigue, and a nonproductive cough. She states that she can hardly walk to the bathroom from her bedroom without having to stop to rest. Her lower legs are swollen with 3+ edema, and she states that she has gained about 8 pounds over the past few days. When questioned about her medications, she states, “I have been skipping my fluid pill because I hate having to go to the bathroom so much. I get so short of breath.” Vital signs: Temperature 99.9°F (37.7°C), Pulse 110/bpm and regular, Respirations 28/min, Blood Pressure 188/98 mm Hg.  She is admitted to the telemetry unit with a diagnosis of exacerbation of heart failure, and given prophylactic anticoagulant therapy, aggressive diuretic therapy, as well as an ACE inhibitor. After a week, the nurse documents the following assessment findings.  Which assessment findings indicate the interventions have been effective (select two)

A health care provider adds a second medication for blood pressure control for a client whose blood pressure has not been well-controlled with one antihypertensive medication.  If the health care provider orders the following medication combination, which combination should the nurse question? 

A client receives instructions on the use of warfarin.  Which statement indicates the client understands the teaching about this medication?

The nurse is teaching a postmenopausal client about the use of calcium to reduce the risk of osteoporosis.  The client asks: “Why do I have to take vitamin D with my calcium?”  What is the nurse’s best response?

A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should:

A client with an ankle wound is admitted with possible osteomyelitis.  The client’s temperature is 102 degree F and the ankle is red, warm, swollen and is persistently draining.  Based on the client’s status, which HCP order should the nurse plan to defer until later? 

The surgical nurse is admitting a client to the operating room.  Which information would require the nurse to call a time-out?

During a routine health examination, a 48-year-old male patient is found to have a total cholesterol level of 224 mg/dl, a triglyceride level 180 mg/dl, and an LDL level of 140 mg/dl.  The nurse teaches the patient the diet of Therapeutic Lifestyle Changes.  Which statement would indicate the patient teaching has been effective. 

The physician orders lisinopril and furosemide to be administered concomitantly (same time) to the client with hypertension.  The nurse should: