Cancer
A client receiving chemotherapy has multiple lab results. This finding, indicating risk for life-threatening infection, is the most important one for the nurse to report immediately to the provider.
What is a low white blood cell count (neutropenia)?
A client with chronic heart failure reports waking up at night feeling like they were suffocating. The nurse documents this finding as this classic manifestation of left-sided heart failure.
What is paroxysmal nocturnal dyspnea?
A 56-year-old male presents to the ED with chest pain radiating to the left arm, diaphoresis, shortness of breath, and indigestion-like discomfort. His ECG shows ST elevation, oxygen saturation is 88%, and troponin levels are elevated.
What is an acute myocardial infarction (ST-elevation MI)?
For a client admitted with acute shortness of breath, this diagnostic test is most useful to help the nurse determine if heart failure is the cause.
What is a B-type natriuretic peptide (BNP) test?
A client receiving chemotherapy and radiation for metastatic breast cancer develops neutropenia. The nurse should include this restriction in the plan of care to reduce infection risk.
What is restrict fresh fruits, vegetables, and flowers?
When a client scheduled for a breast biopsy asks about the difference between a benign and malignant tumor, the nurse correctly explains that this type of tumor grows slowly, does not spread to other tissues, and is usually not life-threatening.
What is a benign tumor?
In clients with acute decompensated heart failure, this type of drug therapy is used to reduce volume overload by promoting diuresis.
What are loop diuretics (e.g., furosemide)?
A client with a myocardial infarction presents with jugular venous distention, weight gain, peripheral edema, and tachycardia. These findings suggest this complication.
What is right-sided heart failure?
For a client with chest pain, this electrocardiographic (ECG) change is the most important for the nurse to report rapidly to the health care provider because it indicates acute myocardial injury.
What is ST-segment elevation?
When teaching a client with hypertension about dietary changes to reduce the risk of coronary artery disease, MI, kidney disease, and stroke, the nurse reinforces this principle from the DASH eating guidelines.
What is “Increase intake of fruits, vegetables, whole grains, and low-fat dairy while limiting sodium, red meats, and sweets”?
After receiving the change-of-shift report on the oncology unit, the nurse should assess this client first: the one with fever and low white blood cell count, indicating possible neutropenic infection.
Who is the client with fever and neutropenia?
A client with hypertension, treated with a diuretic and an ACE inhibitor, comes to the ED with a severe headache, nausea, and a blood pressure of 238/118 mm Hg. To follow up on these findings, the nurse should ask this question first.
What is “Have you consistently taken your medications?”
During the first 48 hours after a myocardial infarction, the nurse’s highest priority is monitoring the client for this complication, which is the most common cause of death in the early post-MI period.
What is dysrhythmias (ventricular arrhythmias)?
A client with dilated cardiomyopathy has had new-onset atrial fibrillation for several days that has not responded to drug therapy. The nurse should include teaching about this therapy to reduce the risk of stroke.
What is anticoagulant therapy?
This common symptom of left-sided heart failure occurs when fluid backs up into the lungs, causing shortness of breath and crackles on auscultation.
What is pulmonary congestion?
An older adult client with colorectal cancer is receiving IV fluids at 175 mL/hr along with chemotherapy. This clinical finding, suggesting fluid overload, is the most important for the nurse to report to the health care provider.
What is lung crackles (pulmonary edema/respiratory distress)?
A client recently diagnosed with hypertension has lab results pending. The nurse knows this result is the most important to report to the health care provider because it indicates possible kidney damage.
What is an elevated creatinine level?
A client with acute coronary syndrome has just returned to the coronary care unit after angioplasty with stent placement. This assessment finding requires immediate action by the nurse because it may indicate stent re-occlusion.
What is reports of chest pain?
A client with symptomatic type I, second-degree atrioventricular (AV) block is treated with IV atropine. This assessment finding indicates the medication has been effective.
What is an increased heart rate?
Clients with heart failure are taught to monitor this measurement every day at the same time, since a sudden increase may indicate fluid retention.
What is daily weight?
A client with lung cancer is scheduled for a lobectomy. The nurse prepares the client to expect this intervention after the procedure to help re-expand the lung and promote breathing.
What is a chest tube?
When teaching a client newly diagnosed with hypertension, the nurse emphasizes this key fact about why regular monitoring and treatment are essential—even when the client feels fine.
What is hypertension is usually asymptomatic until target organ damage occurs?
A client admitted with syncopal episodes of unknown origin is at high risk for falls. To promote safety, the nurse should include this action in the plan of care.
What is instruct the client to call for assistance when getting out of bed?
A client has a sinus rhythm with a heart rate of 72 beats/min. The nurse notes the PR interval is 0.24 seconds, indicating a first-degree AV block. What action should the nurse take?
What is document the findings and monitor the patient?
This type of EKG rhythm change is the most important for a nurse to report immediately, as it signals inadequate perfusion and can be life-threatening.
What is ventricular fibrillation or sustained ventricular tachycardia?