Your assessment of L.J. reveals bibasilar crackles with moist cough; normal heart sounds; blood pressure (BP) 138/88 mm Hg; pulse 104 beats/min; 3+ pitting edema of right lower extremity; mild erythema of right foot and calf; and severe right calf pain

He is awake, alert, and oriented but a little restless. His Spo2
is 92% on room air. He denies chest pain but does have shortness of breath with exertion. He states he is
anxious about missing his grandson's wedding. He denies any voiding problems.

Your institution uses electronic charting. Based on the assessment noted previously which of
the following systems would you mark as "abnormal" as you document your findings? For
abnormal findings provide a brief narrative note.


? Neurologic: Awake, alert, and oriented, but restless.
? Respiratory: Bibasilar crackles with moist cough. Spo2 92% on room air. States he is short of breath
on exertion.
? Cardiovascular: BP 138/88 mm Hg; pulse 104 beats/min.
? Genitourinary:
? Skin: 3+ pitting edema of right lower extremity; mild erythema of right foot and calf.
? Psychosocial: States he is "anxious" about missing his grandson's wedding.
? Pain: Complains of severe right calf pain.

Nursing

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a. Assign only males to care for the resident. b. Chastise the resident for lewd behavior. c. Restrain the hands of the resident during routine care. d. Modify clothing choices to one-piece garments or elastic waist trousers.

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The nurse needs to prepare 250 mL of 2/3 strength hydrogen peroxide. How many mL of sterile normal saline will the nurse use in this solution?

1. 62.5 mL 2. 75 mL 3. 125 mL 4. 250.5 mL

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