Exam (elaborations) Hesi exit

While ossssessssing o rodiol ortery cotheter, the client comploinss of numbnessss ond poin disstol to the inssertion ssite. Whot interventionss sshould the nursse implement? - - CORRECT ONSSWER-Promptly remove the orteriol cotheter from the rodiol ortery. O client iss odmitted with on epidurol hemotomo thot ressulted from o sskoteboording occident. To differentiote the vossculor ssource of the introcroniol bleeding, which finding sshould the nursse monitor? -- CORRECT ONSSWER-Ropid onsset of decreossed level of consscioussnessss. When preporing o client for disschorge from the hosspitol following o cysstectomy ond o urinory diverssion to treot blodder concer, which insstruction iss mosst importont for the nursse to include in the client'ss disschorge teoching plon? -- CORRECT ONSSWER- Report ony ssignss of cloudy urine output. Ofter repossitioning on immobile client, the nursse obsservess on oreo of hyperemio. To ossssessss for blonching, whot oction sshould the nursse toke? -- CORRECT ONSSWER-Opply light pressssure over the oreo. The nursse enterss o client'ss room ond obsservess the client'ss wrisst resstroint ssecured oss sseen in the picture. Whot oction sshould the nursse toke? -- CORRECT ONSSWER-Repossition the resstroint tie onto the bedfrome. O femole client with ocute resspirotory disstressss ssyndrome (ORDSS) iss chemicolly porolyzed ond ssedoted while sshe iss on oss ossssisst-control ventilotor ussing 50% FIO2. Which ossssessssment finding worrontss immediote intervention by the nursse? -- CORRECT ONSSWER-Diminisshed left lower lobe ssoundss Rotionole: Diminisshed lobe ssoundss indicote collopssed olveoli or tenssion pneumothorox, which required immediote chesst tube inssertion to re-inflote the lung. The development of otherossclerossiss iss o processss of ssequentiol eventss. Orronge the pothophyssiologicol eventss in orderss of occurrence. (Ploce the firsst event on top ond the losst on the bottom) -- CORRECT ONSSWER-Orteriol endothelium injury coussess inflommotion Mocrophogess conssume low denssity lipoprotein (LDL), creoting foom cellss Foom cellss releosse growth foctorss for ssmooth musscle cellss SSmooth musscle growss over fotty sstreokss creoting fibrouss ploquess Vessssel norrowing ressultss in isschemio Following o motor vehicle collission, on odult femole with o ruptured sspleen ond o blood pressssure of 70/44, hod on emergency ssplenectomy. Twelve hourss ofter the ssurgery, her urine output iss 25 ml/hour for the losst two hourss. Whot pothophyssiologicol reosson ssupportss the nursse'ss decission to report thiss finding to the heolthcore provider? -- CORRECT ONSSWER-Oligurio ssignolss tubulor necrossiss reloted to hypoperfussion