Applying the nursing process, what is the nurse’s best independent intervention to evaluate the outcome of tracheostomy suctioning immediately following the suctioning?

You are administering heparin and following the protocol below for a client weighing 251 lbs. The order is to administer an initial heparin IV bolus followed by a titrated IV infusion.  Round to the tenths place. HEPARIN PROTOCOL Initial bolus- 60 units/kg Initial rate – 12 units/kg/h Obtain a PTT every 6 hours, and adjust dosage and rate as follows: If a PTT is less than 35 secs:      Repeat bolus with 40 units/kg and increase the rate by 4 units/kg/h. If a PTT is 36 to 44 seconds:       If a PTT is 36 to 44 seconds:          Repeat bolus with 20 units/kg and increase the rate by 2 units/kg/h. If a PTT is 45 to 75 seconds:       Continue current rate. If a PTT is 76 to 90 seconds:       Decrease rate by 2 units/kg/h. If a PTT is greater than 90 secs: Hold the heparin for 1 hour and decrease rate by 3 units/kg/h. Available (for bolus)  – heparin 1,000 units/mLAvailable (for infusion) –  heparin 25,000 units in 250 mL D5W How many mL of heparin will the client receive for the initial IV bolus?

As the home health nurse, you are taking an admission history for a client who has deep vein thrombosis (DVT) and is taking warfarin 2 mg. daily. Which statement by the client is the best indicator that additional teaching about warfarin may be needed?

The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant.  The client is anxious, restless and has a bluish, dusky color around the mouth.  Which order from the healthcare provider should the nurse implement first?

The nurse is caring for a client with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a client with an indwelling catheter?  

A nurse is teaching a client about secondary prevention for cancer.  Which of the following statements by the client best indicates an understanding of the teaching?

The nurse is caring for a client who is admitted with an exacerbation of Systemic Lupus Erythematosus (SLE). Which assessment finding by the nurse is of the priority? 

An older adult presents to the emergency department with disorientation and confusion. There is no further sign of neurological impairment, no weakness in extremities. Based on these observations, the nurse’s priority assessment should be focused on which body systems? 

Which client should be seen by the nurse FIRST after having received shift report?

The nurse working on the postoperative unit receives report on the following clients. Which client should the nurse prioritize to assess?