“Wound drainage is not included in output measurement.” “I only need to count urinary output for my output total.” “I don’t need to count the client’s emesis since it was a small amount.” “I will include all IV fluids, liquids the client drank, IV flushes, and IV antibiotics in my intake total.”
A 47-year-old client presents to the emergency department with severe hypotension, muscle weakness, fatigue, and vomiting. Labs reveal a potassium level of 6.1 mEq/L and a sodium level of 128 mEq/l. Which of the following should the nurse anticipate for this client?
administration of IV spironolactone boluses of Lactated Ringer’s to increase blood pressure administration of IV saline, dextrose, or hydrocortisone boluses of 0.45% normal saline with 40 mEq/L of potassium
The nurse is caring for a client in the ICU who has an arterial line for hemodynamic monitoring. Which action will the nurse take in caring for this client?
position the client with the transducer at the level of the right atrium position the client with the transducer at the level of the left ventricle position the client with the transducer at the level of the right clavicle position the client with the transducer at the level of the right ventricle
The nurse is caring for a client who just returned from a right mastectomy. Which position does the nurse anticipate for the client?
high Fowler’s with the unaffected arm elevated on a pillow flat with the client positioned on the affected side or back semi-Fowler’s with the affected arm supported on a pillow reverse Trendelenburg’s with the arm on the affected side supported on a pillow
The nurse is caring for a client who is HIV positive and gave birth to a full-term infant. The nurse is teaching the client about infections in HIV-positive infants. Which infection does the nurse understand is the most common opportunistic infection in children and infants with HIV?
hepatitis C strep throat cytomegalovirus infection Pneumocystis jiroveci pneumonia
The nurse is precepting a student nurse on leukemia classifications. Which statement by the student nurse reflects an understanding of classifications of leukemia?
“Acute lymphocytic leukemia has an average age of onset of 15 to 39 years.” “Chronic myelogenous leukemia contains mostly granulocytes in the bone marrow.” “Chronic myelogenous leukemia has mostly lymphocytes found in the bone marrow.” “Acute myelogenous leukemia has primarily granulocytes present in the bone marrow.”
The nurse is caring for a client with a T-tube following a cholecystectomy. Which statement is correct regarding management of these tubes?
keep the drainage system at the level of the heart report foul order and purulent drainage to the health care provider remove the tube when drainage slows to less than 50 mL every 8 hours do not clamp or irrigate the T-tube without orders from the health care provider clamp the tube before meals and…
The nurse is providing dietary teaching to the parents of a 7-year-old child with celiac disease. Which statement by the parents indicate that dietary teaching was successful?
“We will serve rice more often.” “We will serve pretzels as a snack.” “I will use rye bread for sandwiches.” “We will start having steel-cut oatmeal for breakfast.”
The nurse notes irritability, microcephaly, and short palpebral fissures in a newborn in the nursery. The nurse suspects which diagnosis for this infant?
syphilis TORCH syndrome brachial plexus injury fetal alcohol syndrome (FAS)
The nurse is caring for a client with a diagnosis of upper GI bleeding. Which findings on physical assessment are consistent with this diagnosis?
increased heart rate decreased heart rate increased hemoglobin bounding peripheral pulses