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Airway depth for oropharyngeal suctioning is measured by
direct bilirubin 2.0mg/dl
no urine output for 2 hours
determining the distance from the corner of the mouth to the earlobe
client reports abdominal pain radiating to shoulder and has a fever
clubbing of fingers and cyanotic lips
glucose level and ausluctation of lungs for presence of crackles
bronchospasms
perform Valsalva maneuver during removal
A client had a Whipple procedure 3 days ago. Which of the following assessments is most important for the nurse to follow up?
direct bilirubin 2.0mg/dl
no urine output for 2 hours
determining the distance from the corner of the mouth to the earlobe
client reports abdominal pain radiating to shoulder and has a fever
clubbing of fingers and cyanotic lips
glucose level and ausluctation of lungs for presence of crackles
bronchospasms
perform Valsalva maneuver during removal
A nurse is caring for a client following a bronchoscopy. Which of the following client findings should the nurse report immediately?
direct bilirubin 2.0mg/dl
no urine output for 2 hours
determining the distance from the corner of the mouth to the earlobe
client reports abdominal pain radiating to shoulder and has a fever
clubbing of fingers and cyanotic lips
glucose level and ausluctation of lungs for presence of crackles
bronchospasms
perform Valsalva maneuver during removal
A client is taking acetaminophen on a consistent basis. Which of the following client findings indicates possible acetaminophen toxicity?
direct bilirubin 2.0mg/dl
no urine output for 2 hours
determining the distance from the corner of the mouth to the earlobe
client reports abdominal pain radiating to shoulder and has a fever
clubbing of fingers and cyanotic lips
glucose level and ausluctation of lungs for presence of crackles
bronchospasms
perform Valsalva maneuver during removal
Which of the following assessment data is most important for a nurse to report to the primary care provider?
direct bilirubin 2.0mg/dl
no urine output for 2 hours
determining the distance from the corner of the mouth to the earlobe
client reports abdominal pain radiating to shoulder and has a fever
clubbing of fingers and cyanotic lips
glucose level and ausluctation of lungs for presence of crackles
bronchospasms
perform Valsalva maneuver during removal
A nurse is assisting a primary care provider with removal of a chest tube. The nurse should instruct the client to
direct bilirubin 2.0mg/dl
no urine output for 2 hours
determining the distance from the corner of the mouth to the earlobe
client reports abdominal pain radiating to shoulder and has a fever
clubbing of fingers and cyanotic lips
glucose level and ausluctation of lungs for presence of crackles
bronchospasms
perform Valsalva maneuver during removal
A client with renal calculus has a Foley catheter and an IV of NS at 150ml/hr. Which of the following findings warrants immediate reporting?
direct bilirubin 2.0mg/dl
no urine output for 2 hours
determining the distance from the corner of the mouth to the earlobe
client reports abdominal pain radiating to shoulder and has a fever
clubbing of fingers and cyanotic lips
glucose level and ausluctation of lungs for presence of crackles
bronchospasms
perform Valsalva maneuver during removal
A client is started on TPN for chronic pancreatitis. The most important assessments for the nurse to make 24 hours later are
direct bilirubin 2.0mg/dl
no urine output for 2 hours
determining the distance from the corner of the mouth to the earlobe
client reports abdominal pain radiating to shoulder and has a fever
clubbing of fingers and cyanotic lips
glucose level and ausluctation of lungs for presence of crackles
bronchospasms
perform Valsalva maneuver during removal
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