The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic
... [Show More] acidosis?
Chloride 100 mEq/L (100 mmol/L)
Sodium 130 mEq/L (130 mmol/L)
Hemoglobin 15 g/dL (150 g//L)
PaCO2 30 mm Hg - correct answer PaCO2 30 mm Hg
The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home?
Able to ambulate in the hallway with assistance
Post-operative pain is managed
Correct response
Able to tolerate a regular diet
Psychological counseling is scheduled - correct answer Post-operative pain is managed
A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first?
Test deep tendon reflexes
Check blood calcium level
Check complete blood count (CBC) with differential
Check serum potassium level - correct answer Check complete blood count (CBC) with differential
Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ.
The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next?
Place the client into the bed and administer the ordered PRN analgesic
Measure the client's respirations, blood pressure, temperature and pupillary responses
Check the client for bladder distention and the urinary catheter for kinks
Assist client with relaxation techniques - correct answer Check the client for bladder distention and the urinary catheter for kinks
These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus.
The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first?
Administer the ordered PRN medication [Show Less]