The nurse is reviewing the lab results of several clients. Which finding should the nurse report to the health care provider?
- client who has sodium levels of 140 mEq/L
- client who reports nausea with lithium level of 1.8 mEq/L
- client with heart rate of 62 bpm who has a digoxin level of 1.4 ng/mL
- A pregnant women whose fibrinogen level is 500mg/dL
Client who reports nausea with lithium level of 1.8.
- this patient has lithium toxicity. Lithium has a narrow therapeutic range of 0.6-1.2 mEq/L
You walk into your clients room and they say, “ I haven’t gotten any sleep while being in this hospital.” Which response by the nurse illustrates a therapeutic communication with the client?
- “don’t worry, you will sleep well tonight”
- “you’re having trouble sleeping while being in the hospital?”
- “I’m sorry”
- “I would have a hard tie, sleeping here also”
“You’re having trouble sleeping while in the hospital “
- This is an open ended question and shows active listening skills, both of which display a therapeutic response
You are a nurse working in a long term care facility. You are caring for a client with end stage Alzheimer’s disease. What communication techniques are appropriate to use when speaking with your client?
- ask open ended questions
- speak loudly so they can hear
- turn up the television so they can hear it better
- use simple statements and questions
- face the client while speaking
Pick all that apply
Use simple statements and questions
Face the client while speaking
The nurse working in a OBGYN clinic is collecting data from a pregnant client who is 8 weeks pregnant. Which of the following statements by the client needs further intervention?
- client reports breast tenderness
- client reports feeling extreme fatigue
- client reports vaginal discharge that is white
- client is taking enalapril for hypertension
Client is taking Enalapril for hypertension
- ace inhibitors
Remember: suffix ACE = “pril “
Meaning these medications are teratogenic- causing harm to the developing fetus and shouldn’t be taken during pregnancy
The nurse in the emergency department receives report on 4 clients. Which client should be seen first ?
- A 55 year old who is NPO asking for a snack
- A 60 year old who has a mean arterial pressure of 80mmhg
- A 20 year old who has a capillary refill of fewer than 3 seconds
- A 35 year old whose right hand is colder than his left
35 year old whose right hand is cooler than his left
- this patient needs immediate attention and should be assessed first due to the risk of losing his hand due to inadequate perfusion and blood supply. This finding could mean that a thrombus (clot) has formed, hemorrhage is occurring, infection, or circulatory impairment has occurred
A client is scheduled for an elective laparoscopic cholecystectomy. The nurse should notify the health care provider (HCP) about what findings before the surgery?
- platelet count of 300,000/mm^3
- temperature of 100.4 f with mild cough
- wbc of 9,000/mm^3
- hemoglobin 15g/dL and hematocrit 48%
Temperature of 100.4 with mild cough
- this may indicate the patient has an infection.
