While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse
... [Show More] implement?
Promptly remove the arterial catheter from the radial artery.
A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?
Rapid onset of decreased level of consciousness.
When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan?
Report any signs of cloudy urine output.
After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take?
Apply light pressure over the area.
The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take?
Reposition the restraint tie onto the bedframe.
A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants
immediate intervention by the nurse?
Diminished left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required
immediate chest tube insertion to re-inflate the lung.
The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom)
Arterial endothelium injury causes inflammation
Macrophages consume low density lipoprotein (LDL), creating foam cells
Foam cells release growth factors for smooth muscle cells
Smooth muscle grows over fatty streaks creating fibrous plaques
Vessel narrowing results in ischemia
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider?
Oliguria signals tubular necrosis related to hypoperfusion
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?
Skills of staff and client acuity [Show Less]