S: 33-year-old female client with a 2-day history of feeling unwell has come to the emergency department today. She has been experiencing general fatigue, aches, chills, and decreased appetite over the past two days. In the last 12 hours, she has had new onset of shortness of breath with exertion, fever, and frequent cough productive of small amounts of yellow sputum. A Chest X-ray is completed which shows pneumonia in the right lung. B: Client is a healthy adult with no past medical history. A: T 102.6 F, HR 116, RR 28, BP 114/76, SpO2 88% on Room Air. Client is alert & oriented x4, mildly anxious, with increased work of breathing, and a flushed appearance. Crackles are auscultated in the right lung, left lung sounds are clear. Radial and pedal pulses are strong, she has no peripheral edema. R: What would the expected outcome be for this patient? Choose one of the options provided in the parentheses.  Patient maintains optimal gas exchange as evidenced by __________ (clear lungs sounds in the right lung, maintaining respiratory rate of 12-20, maintaining an oxygen saturation of 92% or higher) by discharge. _______

In regards to the client’s dietary choices, what information will the nurse include in the teaching plan for a client who is taking anticoagulants? 

A post-surgical client has developed a temperature of 101 F, 24 hours after surgery.  The nurse assesses the client and has auscultated scattered crackles and rhonchi throughout the chest.  The nursing diagnosis is ineffective airway clearance.  After performing nursing interventions, which outcome/evaluation would indicate a therapeutic response to treatment? 

A nurse is caring for a client who is terminally ill. Which of the following statements would the nurse identify as a therapeutic response from a family member?

 A client who has pneumonia has had a fever for three days.  What characteristics would the nurse anticipate related to the clients urinary output?   

The nurse is inserting an oropharyngeal airway and the client vomits when it is inserted.  What is the first action that should be taken by the nurse related to the occurrence?

The client has been complaining of shortness of breath for two weeks and has been admitted with the nursing diagnosis of impaired gas exchange. Which diagnostic test result would provide support/evidence for this nursing diagnosis? 

Which nursing diagnosis would be appropriate for a client who has a retention catheter and the drainage bag is found lying on the floor? 

What assessment findings or client conditions would indicate the need for suctioning? Select all that apply.

 What documentation would be most appropriate when recording the results of the administration of a soap suds enema (SSE) to the client?