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The nurse is caring for a client who has returned to post-surgical suite after
postanesthetic recovery from a nephrectomy. The nurse's most recent
assessment reveals increased sedation, shortness of breath, hypotension,
and low urine output over the last 2 hours. What is the nurse's best
response? - 🧠 ANSWER ✔✔
Assess the client for signs of bleeding and inform the primary care provider.
The highest priority for intervention during the first 30 minutes in treating an
acute myocardial infarction including the following(s). Select All That Apply
- 🧠 ANSWER ✔✔Oxygen therapy
Morphine administration
,Nitroglycerin (NTG)
Aspirin (ASA)
A nurse on a busy medical unit provides care for many client who requires
indwelling urinary catheter at some points during their hospital care. - 🧠
ANSWER ✔✔The nurse should recognize a heightened risk of injury
associated with indwelling catheter are in which client?
A client who has Alzheimer disease and who is acutely agitated
While auscultating the heart of a patient admitted for complications
following a myocardial infarction three weeks ago, the nurse notes the
presence of a new S3 heart sounds. - 🧠 ANSWER ✔✔Based on this
finding, what is the nurse's best action at this time?
Assess symptoms of left-sided heart failure
A patient hospitalized for worsening renal failure suddenly becomes
restless and agitated. Your assessment reveals tachycardia, hypertension,
and crackles bilaterally scattered throughout the lung fields. - 🧠 ANSWER
✔✔What do these symptoms suggest?
The patient is developing pulmonary edema
, A client with advanced venous insufficiency is confined to bedrest following
orthopedic surgery. How can the nurse best prevent skin breakdown in the
client's lower extremities? - 🧠 ANSWER ✔✔Ensure the client's heels are
supported and protected.
A nurse has a client with a spinal cord injury and is tailoring the care plan to
prevent the major cause of death for this client. The nurse's care plan
includes assisted coughing techniques, applied sequential compression
device, and prevented pressure injuries. - 🧠 ANSWER ✔✔Which are the
most likely
possible causes of death for this client? Pneumonia, pulmonary embolism,
and sepsis
After a sudden decline in cognition, a 77-year-old client who has been
diagnosed with vascular dementia is receiving care at home. To reduce this
client's risk of future infarcts, which action should the nurse most strongly
encourage? - 🧠 ANSWER ✔✔Rigorous control of the client's blood
pressure and lipid levels.
The nurse is caring for a 78-year-old client who has had an outpatient
cholecystectomy. The nurse is getting the client up for the first walk
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