Rn adult medical surgical online practice 2023 b

A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? (Click on the "exhibit" button for additional information about the client. There are tabs that contain separate categories of data.) Heart rate 55/min Rational: The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider. A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (tens) for the management of bone cancer pain. The nurse should explain that applying a tens unit to the painful area has which of the following effects? A tingling sensation replacing the pain Rational: A tens unit applies small electric currents to the painful area, with the client increasing the current until the "pins and needles" sensation overrides the pain. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing’s triad? Bradycardia Rational: A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing’s triad. The other components of Cushing’s triad are severe hypertension and a widened pulse pressure. A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer’s disease. Which of the following information should the nurse include in the teaching? Create complete outfits and allow the client to select one each day. Rational: The family should place completed outfits on hangers and allow the client to select which one to wear each day. A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a pseudomonas aeruginosa infection? Avoid placing plants or flowers in the client's room. Rational: Live plants can harbor p. Aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room.