1. A nurse is assessing a client whohas left-sided heart failure. Whichof the following findings should the nurse expect?
Bradycardia- more tachycardia
... [Show More] cuz of a failing ventricle, SNS is activated to compensate. Flushed skin- dusklyit wIll look like
Frothy sputum-Left sided- can be blood tinged
Jugular vein distention→RightRationale: ATI MS: pg. 198 ch 32 pdf
Left side: dyspnea, orthopnea, fatigue, pulmonary congestion, frothysputum, organ failure such as oliguria. Right Side: Jugular veindistention, ascending dependent edema, abdominaldistention, polyuria arrest, liver enlargement,
A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where the nurse should expect the client to have referred pain.( Find “hot spots” in the artwork) Pain travels downward to the inguinal area and lower back
Renal colicoccurs in the kidney area. Referredpain is somewhere that happens in another place otherthan where the pain should be felt.
A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions shouldthe nurse take? (Select all the apply?). Check answer i read pg 644-647 med surg it’s not so specific p. 370 ch 57 pdf
monitor the access site fordrainage.- to check forsxs of infection. Strip the catheter tubing
Measure the amount of the dialysate outflow
Raise the client to high fowlers position- they must lie supine Position the client to herotherside.
A nurse is planning to insert an indwelling catheter forafemale client. Which of the following actions should the nurse plan to take? Ati video tutorials foley
Collect urine specimen from the drainage bag 1 hr after insertion Raise the head of the bed to 45 degrees prior to insertion
Secure the catheter to the client's inner thigh
Attach the bag to the rail of the bed. –under non movable area
A nurse is providing teaching foraclient who has age-related maculardegeneration which of the following information should the nurse include in the teaching
A possiblecause of this problemis long-term lack of dietary protein
You probably have a Detachment of yourretina -vision is like having curtains overeyes You probably have noticed adeclinein yourcentral vision
The doctor can perform surgery to correct the start paying the folds in your retina
Rationale: ATI MS: PG. 63 Maculardegeneration, often called age-related maculardegeneration(AMD), is the central loss of vision that affects the macula of the eye. NO cure , happens alot in old people. Sxs: distorted vision, blurredvision, caused by smoking, female, HTN, diet lacking carotene.
A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? P . 357 ch 55 pdf Med surg
Platelets 70,000/mm3- risk of bleed normal range is 150,000 - 300,00- ABCS is compromised automatically. Distended abdomen- expected
Alkalinephosphatase 125 units/L-norm normal is 30 -120 D. Clay colored stools- bile not on yourshit
A nurse is preparing to discontinuelong-term total parenteralnutrition (TPN) therapyforaclient foraclient. The nurse should plan to discontinuethe TPN gradually to reduce the risk of which of the following adverse effects? Old med surge docs we used
Hyperglycemia Diarrhea Constipation
Hypoglycemia (Repeat) Sinceyourbody is producing enough insulin to take on higher loads, you must taperit down to avoid hypoglycemia with lowerconcentrations of
TPN
Abruptly discontinuing TPN willcause reboundhypoglycemia
A nurse is preparing to administer aunit of packed RBCs to a client. Which of the following actions should the nurse plan to take? P
. 250 chapter 40 pdf p . 678 lewis
Administer the unit of packed RBC’s over 1 hr- 2- 4 hr its must be given for 2 -4 hours. older adults
Obtain the client’s first set of vitalsigns 1 hrafterinitiating the transfusion- you get vital signs at the initial first 15 to 30 minutes of the transfusion.
Initiate venousaccess with a 21-gauge needle - no more than 19, for a regular adult it is 18 or 20 . Use Y tubing with 0.9% sodium chloride when administering the transfusion. Pg 249
TOXIC SHOCK SYNDROME- same
A nurse is providing discharge teaching to an olderadult client who had an exacerbation of COPD. The client is to start fluticasoneby metered-doseinhaler. WHich of the following instructions should the nurse include? ( C) p . 132 ch 22
Use fluticasone as needed forshortness of breath.- fluticasoneusedto treat inflammation. Limit fluid intake to 1 L perday. - drink plenty to avoid dehydration. 2-3 liters.
Obtain a yearly influenza immunization. - reduce risk of infection.
Assist use of pursed-lip breathing.- this is also one of the interventions the nurse does but the question ask about fluticasone. It is asteroid, and we all know steroidsdecresaes inflammation but also depress our immunue system. So getting aflu shot is priority.
A nurse is providing discharge teaching to an olderadult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
“You can cross your legs at the ankles when sitting down.”-avoid flexion contraction “Clean the incisiondailywith hydrogenperoxide.”- soap and water
“Install a raised toilet seat in your bathroom.” Pg 437 also use straight chairs with arms, abduction pillow betweenthe legs, avoidlow chairs, and flexion of hip greaterthan 90 degrees. NO crossing legs , no turing on operative side.
“You should use an incentive spirometer every 8 hrs.”- once every hour at least Missing
A nurse is caring fora client who is postoperativefollowing afemur fracture. Which of the following findings should the nurse report to the provider immediately?
The client reports shortness of breath - embolism ABCS p . 457 chapter 71 The client has a temperature of 38.1 C (100.5F)
The clients incisionis red and warm The client reports incision p [Show Less]