HESI MED SURG
The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA). What actions will the nurse include
... [Show More] in the client's plan of care? (Select all that apply.)
A. Frequent vital signs.
B. Determine if the client is allergic to aspirin.
D. Offer fluids of choice.
F. Monitor infusion of IV nitroglycerine.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?
C. Potassium
Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium; hypokalemia; hypertension is the most prominent and universal sign.
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all that apply.)
A. Facial muscle spasms
B. Sudden facial pain
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V).
A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, the client is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which action should the nurse take first?
D. Add 5 cm positive end-expiratory pressure (PEEP)
Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level
The clinic nurse is providing post-operative teaching for a client scheduled for a myringoplasty. Which client statements indicate to the nurse that the teaching has been effective? (Select all that apply.)
B."I will avoid forceful and deep coughing until my post-op checkup.
C."I must lay flat on my non-operative side for the first 12 hours after surgery."
D. "My hearing may be less or muffled until the packing comes out."
The client must keep the ear bandage clean and dry until the packing is removed. Showering and hair washing is discouraged.
During the shift report, the charge nurse informs a nurse of a reassignment to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings when preparing to leave. What is the best immediate action for the charge nurse to take?
A.
Continue with the shift report and talk to the nurse about the incident at a later time.
Continuing with the shift report is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private.
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