check for a pulse insert a urinary catheter prepare to shock the client administer a bolus of sodium bicarbonate
The nurse is caring for a client with abdominal aortic aneurysm. Which observation by the nurse indicates the need for immediate intervention?
complaints of yellow-tinted vision sudden onset of frothy, pink sputum urinary output of 75 mL/hr. per urinary catheter complaints of sudden and severe back pain and shortness of breath
The nurse is caring for a client who presents to the ED with the following arterial blood gas (ABG) results:
The nurse is caring for a client who presents to the ED with the following arterial blood gas (ABG) results: pH 7.32 PaCO2 47 mm Hg HCO3 24 mEq/L PaO2 91 mm Hg Which clinical manifestation would the nurse anticipate, based on these findings? confusion nausea and vomiting deep, rapid respirations hypoventilation with hypoxia
The nurse is caring for a client at risk for postpartum hemorrhage. Which early sign of hemorrhage should the nurse monitor for this client?
coma hypotension restlessness cool, clammy skin
The nurse is caring for a 9-year-old boy who presented to the ED after a penetrating injury from a BB gun. The client is diagnosed with a hyphema. The nurse proceeds to place the client in which position?
flat in bed semi-Fowler’s Trendelenburg’s lateral on the unaffected side
The nurse is teaching a client about peritoneal dialysis. Which complication of this treatment would the nurse instruct the client to report?
bone pain confusion muscle cramps cloudy outflow
The nurse is performing hemodialysis on a client, with the understanding that air embolus is a complication of this treatment. Which assessment findings by the nurse indicate an air embolus?
cold intolerance chest pain and anxiety decreased respirations hypertension and widening pulse pressure
The nurse is caring for a client who is HIV-positive. The nurse understands which of the following to be true regarding HIV and AIDS?
Viral load testing monitors disease progression and evaluates effectiveness of treatment. The Western blot test is positive if antibodies to at least three major HIV antigens are present. Patients with AIDS present with a white blood cell (WBC) count between 5,000 and 10,000 cells/mm3 . An enzyme-linked immunosorbent assay (ELISA) test can detect the presence of…
The nurse is assessing a client with Graves’ disease. Which assessment finding would the nurse expect in this client?
bradycardia constipation exophthalmos recent weight gain
The nurse is caring for a client with a history of cirrhosis of the liver. Lab values reveal rising ammonia levels. Which of the following actions should the nurse anticipate performing? Select all that apply.
replace electric razor with a straight razor encourage frequent periods of rest instruct on a potassium-restricted diet monitor the client’s mental status