The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube remains patent and is draining moderate amounts of greenish fluid. Which assessment finding would suggest that the client’s potassium level is too low?

Case Study Question #1: The nurse cares for a 72-year-old female admitted to the medical unit with dehydration and secondary diagnosis of mid-stage Alzheimer’s disease.  Phase Sheet   Name Theresa Peters Gender F Age 72 Weight (lbs/kg) 122 lb (55 kg) Allergies NKA Nurses’ Notes   DAY 1 1800:  Client admitted from ED to medical unit for dehydration after several days of poor PO intake where she appeared to briefly lose consciousness this am after breakfast. Retired for several years as seamstress and husband passed away last year. Now lives with daughter/family due to recent diagnosis of middle stage Alzheimer’s disease, history of mild hypertension & gastroesophageal reflux.  Daughter notes appetite has diminished in past 2-3 weeks, and it is hard to get her to drink enough fluids even in the warmer weather.  She has been more “down in the dumps” the past few weeks. Client has been unsteady on her feet due to dizziness and increasingly weak. P: 104 and B/P 102/62 (sitting) & 94/55 (standing). Skin & mucous membranes dry; tenting noted. Admission BUN & creatinine elevated. Foley inserted and draining concentrated amber urine. Provider notified; ordered fluid challenge of 500 ml normal saline. Alert/oriented to name only, answers questions, pleasant, cooperative, asking for daughter. Vital Signs   Time 1800   T ◦F/ ◦C 97.8 F /36.5 C   P 104   RR 20   B/P 102/62   Pulse oximeter 97   Oxygen Room air   Laboratory Report   Lab Results @ 1400 (ED) Reference Range Sodium 145 135 to 145 mEq/L Potassium 5.0 3.5 to 5.0 mEq/L Glucose (fasting) 72 Normal

While assessing a client’s peripheral IV site, the nurse observes edema and coolness around the insertion site. How should the nurse document this observation?

A nurse is caring for a client who has experienced significant blood loss following a traumatic injury. The client is tachycardic, pale, and has an SpO₂ of 89% on room air. Which of the following best explains the client’s impaired gas exchange?

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?

Place these nursing actions in order of proper sequence for preparing an IV solution and tubing when initiating an intravenous infusion.  When recording your answer below, enter the number only, that corresponds to your choice.  1. Clamp tubing, uncap spike, and insert spike into entry site on the solution bag as directed by the manufacturer 2. Verify the primary care providers orders, gather all supplies and wash your hands, identify the patient 3. Label tubing with date of initiation, due date to replace tubing, and name. 4. Maintain aseptic technique when opening sterile packages and IV solutions 5. Prime the tubing eliminate all air, by releasing the clamp that allows fluid to move through the tubing prior to initiating the infusion 6. Squeeze the drip chamber and allow it to fill one-half full or as indicated by the manufacturer and open the IV tubing clamp.

You are the nurse caring for a trauma patient who presents to the ER following an automobile accident. The primary care provider prescribes the nurse to start an IV with a large bore needle to infuse fluids rapidly. What gauge catheter is the best choice for this situation?

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. Vital Signs       Time  1000   Oral Temp  99.0 F (37.2C)   Pulse 104   Respiratory Rate 27   Blood Pressure 157/86   Pulse oximeter  91% Room air   Pain  0   Which condition is the client most likely experiencing?

A client who has a history of chronic lung disease is admitted to the hospital with possible pneumonia. Respirations are shallow and breath sounds are diminished. Blood gases reveal: pH – 7.25, PCO2 – 70, HCO3- 24.  What acid-base imbalance is this client experiencing?

Which clinical manifestation indicates to the nurse that the client has pneumonia?