The nurse admits the client with clear lungs and, 2 days later, determines the client has fluid in the left lung. Which should the nurse implement next? (Select all that apply.)
1. Reposition the client for comfort
2. Obtain a stat portable chest x-ray
3. Notify the physician immediately
4. Complete the respiratory assessment
4
4 and 2. The provider should be notified promptly, but the nurse presents a more comprehensive client assessment by completing the respiratory examination first, as long as the client is not in acute distress. Because this is a new finding for the client, the nurse facilitates suitable client care by presenting a comprehensive client assess-ment to the provider.
1. The nurse collaborates for a chest x-ray.
3. The nurse can reposition the client for comfort but should ensure optimal chest expansion to help mobilize the pulmonary secretions for expectoration.
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Within the first hour following a vaginal delivery, the nurse assesses the mother and finds the fundus is firm and there is a trickle of bright red blood. The nurse recognizes that:
a. this is a normal occurrence. b. this is abnormal and should be reported. c. the perineum needs to be checked frequently. d. the patient should be restricted to bed rest.
A client is seen in the emergency department complaining of sudden onset of a throbbing headache. The client is taking a monoamine oxidase inhibitor (MAOI), and admits to having eaten a lot of aged cheese recently
The nurse should assess the client for which other symptoms? 1. Abdominal cramping 2. Hypotension 3. Stiff neck 4. Diaphoresis
Which newborn is at higher risk for developing hypoglycemia? (Select all that apply.)
a. Post-term newborn b. 38 weeks' gestation newborn c. Small-for-gestational-age newborn d. Large-for-gestational-age newborn e. Term newborn born by cesarean birth
The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The ABG findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. The nurse would anticipate which initial intervention to correct this problem?
1. Encourage the patient to breathe in and out slowly into a paper bag. 2. Immediately administer oxygen via a mask and monitor oxygen saturation. 3. Prepare to start intravenous fluid bolus using isotonic fluids. 4. Anticipate the administration of sodium bicarbonate via the IV route.