While reviewing the laboratory results for a client, the RN notes that pulmonary function test values are as follows: residual volume: 1800 mL; vital capacity: 2300 mL; tidal volume: 275 mL.
Identify the nursing action included in the care plan developed by the LPN that the RN would change.
a. Increase fluid intake to 3500 mL per day.
b. Position the client in the high-Fowler's position.
c. Contact the dietitian to arrange for a six-feeding, small-portion diet.
d. Increase the oxygen flow rate to 10 L/min by rebreather mask for shortness of breath.
During the 0700 beginning of the shift assessment, the nurse finds a client who was diagnosed with type I diabetes mellitus to be difficult to arouse.
Per unit protocol, arterial blood gases and a blood glucose are performed. The results show pH 7.01, PO2 92, PCO2 36, HCO3 9, blood glu-cose 873 . What action should the nurse take first?
a. Administer the client's 0800 dose of NPH insulin immediately.
b. Notify the physician and the house super-visor of the client's condition.
c. Begin an IV line with 0.5 normal saline and prepare sodium bicarbonate for ad-ministration.
d. Attempt to arouse the client and determine what he ate the previous evening to raise his blood glucose.
After reviewing the lab results for the clients to which the nurse is assigned, select the client the nurse should assess first.
a. 53-year-old man with a CPKMB of 3
b. 33-year-old man with a cTnT2 of 0.8 ng/mL
c. 48-year-old woman with a LDH1 of 25
d. 64-year-old woman with a triglyceride level of 175 mg/dL
After a client is connected to a heart monitor in the emergency room, the nurse notes an elevated ST segment on the ECG strip. What nursing action would have the highest priority for this client?
a. Assess the vital signs and the degree and location of any chest pain.
b. Administer a stat dose of sublingual ni-troglycerine spray to dilate the coronary arteries.
c. Notify the physician of the client's dire condition.
d. Place the client in the prone position to reduce the workload of the heart.
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