A nurse is assessing a patient admitted with pneumonia.  Which clinical manifestations would the nurse expect to find.  (Select all that apply).

Case Study Question #3 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.  2200:  B/P and P improved after saline bolus. U/O clear yellow and increased to 240 ml in past 4 hrs. Resting quietly, cooperative and no report of dizziness, etc. DAY 2 0800: IV normal saline running at 75 ml/hr. B/P improved to 124/74 and negative for orthostatic changes. Lisinopril dose held this am. Am labs improved—BUN/creatinine WNL. 1200:  VS stable. Not interested in lunch despite reminders to eat. IV normal saline @ 50 ml/hr. Foley draining adequate amts clear yellow urine. Seems more disoriented, anxious and inattentive. Vital Signs   Time 1800 2200 0800 1200   T ◦F/ ◦C 97.8 F /36.5 C 98 F / 36.6 C 97.8 F/36.5 C 98.2/36.7 C   P 104 94 86 84   RR 20 18 16 18   B/P 102/62 110/68 120/72 130/76   Pulse oximeter 97 97 96 97   Oxygen Room air Room air Room air 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

The nurse is assessing an older adult patient and recognizes that aging increases the risk for impaired gas exchange. Which of the following age-related changes contribute to this risk? (Select all that apply)

A nurse is caring for an elderly client that has been vomiting all weekend. What expected findings are associated with excessive vomiting the nurse might discover when performing assessment of this client? Select All that Apply

The registered nurse is the leader of a team consisting of two unlicensed assistive personnel. Which assignments can the nurse delegate to the unlicensed assistive personnel?  SELECT ALL THAT APPLY

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?