The nurse is caring for a 63 year old female with history of hypertension and complaints of shortness of breath.  Day 1: Bilateral breath sounds clear and present throughout, Weight 80kg(176 LB), Urine output 480ml/8 hours. Vital Signs: Temp-99.7, BP 108/50, Pulse 98, Resp rate-20, O2Sat 95% Room Air. Day 4: Breath sounds scattered, crackles heard bilaterally. Apical heart rate rapid and irregular. Audible s3 Gallop. Weight 82.1kg(181 LB). Urine output 320ml/8 hours. Vital Signs: Temp-98.2, BP 138/80,  Pulse 112, Resp rate-28, O2Sat 88% Room Air.  Provider Prescription: Lopressor 25mg PO Daily Lasix 20mg PO BID Potassium 10MEQ BID The nurse is reviewing the clients health history and assessment data. Which of the findings should the nurse address first?

What information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a medical-surgical unit? Select all that apply.

In the care of a client receiving drug therapy for hypertension, which assessment best determines the effectiveness of the medication?

The nurse is educating a client about the care related to a new diagnosis of mitral valve prolapse.  What statement made by the client demonstrates understanding?

A client on the oncology unit undergoing chemotherapy is experiencing pancytopenia. What lab values will the nurse identify that supports this diagnosis? Select all that apply.

An athlete who has had episodes of syncope is being evaluated with a Holter monitor.  What instruction will the nurse give the client to assure that this test provides a comprehensive picture of his cardiac status?

Priority nursing actions for a hospitalized client with a new-onset temperature of 102.2°{“version”:”1.1″,”math”:”°”}F and severe neutropenia include which of the following? Select all that apply.

AS a home health nurse, you are obtaining an admission history for a client with a deep vein thrombosis and is taking warfarin (Coumadin) 2mg daily. Which statement by the client indicates the need for additional medication teaching?

What action will the nurse take when administering Heparin subcutaneously?

Case Summary A 69-year-old male client is admitted to the medical-surgical unit for an evaluation of pain and edema of the right lower extremity. The onset of symptoms was 2 days prior to arrival. Client is diagnosed with a deep vein thrombosis requiring heparin therapy. The nurse on the medical-surgical unit is caring for a 69-year-old male client with pain and swelling of the right lower extremity.   Nurses’ Notes     Day 1. 0930 Admission note: Client admitted from the Emergency Department via stretcher and transferred to bed. Client is alert and oriented. Saline lock IV in the R antecubital vein patent. Right lower extremity noted to have 2+ pedal edema, pain 8/10 in right calf. Warmth noted to right calf. Client has positive motion and sensation to right lower extremity. Right pedal pulse weak, palpable. R lower extremity elevated on 2 pillows.  VS: BP 145/82, HR 96, RR 16, Temp 36.7C (98F). Client ordered to be on complete bedrest. Client made aware 1010: Radiology called results of right leg ultrasound: positive for deep vein thrombosis of the right posterior tibial vein. Provider made aware. New orders pending. 1018: Orders have been entered. Orders   Category Orders Labs: Draw Prothrombin Time (Pt), Partial Thromboplastin Time (PTT) STAT Medications: Administer Heparin 80 units/Kg IV bolus now. After initial bolus begin Heparin Weight-Based Protocol Continuous IV Infusion: Starting dose: 18 units/Kg/hr. Draw serum PTT 6 hours after infusion begins, then Q 6 hours. Call results Nursing: Activity: strict bedrest Place compression stockings on bilateral lower extremities Elevate to right lower extremity Closely monitor for signs of bleeding  The nurse reviews the physician’s orders. Based upon the new information given, what is a priority action by the nurse within the hour of the administration of Heparin 80 units/kg/hr?