Fundamentals of Nursing questiona and answers

Fundamentals of Nursing the nurse reviews the electronic health record system for client information and documents care in the nursing progress notes. client care implemented per standing orders. Which action would the nurse take for a client whose right radial pulse is weak and thready? select all that apply. Once, some, or all may be correct. a. assess all peripheral pulses b. administer intravenous fluids c. assess and compare both radial pulses d. ask a second nurse to assess the clients pulses e. assess the client's pulse oxygenation (SpO2) on that hand f. assess for edema or other issues that may be restricting peripheral blood flow g. observe for pallor/ skin temperature differences distal to the weak pulse h. withhold prescribed antihypertensive medications. - ANSWER: a, c, d, f, g if the clients radial pulse is weak and thready, further assessment would be indicted and includes assessing all peripheral pulses; assessing and comparing both radial pulses; asking another nurse to assess and verify the findings; assessing for any issues that may be restricting peripheral blood flow; and observing colour and temperature differences distal to the weak pulse. the nurse should not administer IV fluids without a roviders order. the SpO2 may not be accurate if measured in an area of impaired circulation and should be assessed on the opposite hand. in this situation the nurse should notify the provider who may subsequently order specific medication, including antihypertensives, to be withheld, but the nurse would not do this without proper orders. the nurse receives report, reviews the electronic health record, and documents care in the nursing progress notes. Labs drawn and diagnostics completed per provider orders. education provided as appropriate. a client who is positive for human immunodeficiency virus (HIV) is admitted to a surgical unit after an orthopedic procedure. select the 2 possible routes of HIV transmission. a. feces b. blood c. semen d. urine e. sweat f. tears - ANSWER: b, c