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The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A.Suctions oral secretions from mouth B.Positions head of bed flat when changing sheets C.Takes temperature using the axillary method D.Keeps head of bed elevated at 30 degrees Correct Answer- B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk...

hyperventilation, if someone is blowing off too much CO2 they become more Correct Answer- Alkaline, respiratory alkalosis if a patient's lung are not functioning very well and they are unable to remove or blow off CO2 very well, the CO2 will build up in their system becoming Correct Answer- acidic, respiratory acidosis Perfusion Correct Answer- is adequate arterial blood flow through the peripheral tissues (peripheral perfusion) and blood that is pumped by the heart to oxygenate major body...

A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? Apical heart rate of 60. Sweating across the forehead. Doesn't suck well. Respiratory rate of 30 breaths per minute. - Correct Answer- Apical heart rate of 60. A heart rate of 60 (A) is much lower than normal for a 6-month-old and warrants immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 BPM when awake, and a rat...

The nurse working in an outpatient nephrology clinic knows that which of the following are primary functions of the kidneys? (Select all that apply.) A. Production of clotting factors B. Homeostasis C. Excretion of metabolic wastes D. Regulation of acid-base balance E. Metabolism of fats Correct Answer-B, C, D The kidneys do not metabolize fats. Production of clotting factors is a primary function of the liver. The kidneys maintain blood pressure using the RAAS and also produce erythrop...

ALS/ACLS - Team Response Scenario - Maurice Van Essen [2022] COMPLETE SOLUTION

The nurse is preparing assignments for the day shift. It is most important that the client with which diagnosis and description is assigned to a RN? A. Menorrhagia: 24 hrs post vaginal hysterectomy. B. MI: 4-days post infarction, transferred from ICU yesterday. C. Depression: Admitted during the night following a suicide attempt with an OD of Tylenol D. Pneumonia: A 4 yo who is receiving IB antibiotics Correct Answer- C. Depression: Admitted during the night following a suicide attempt wit...

301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? Correct Answer- Insensible loss of body fluids contributes to the hemoconcentration of serum solutes. Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration o...

A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is at least likely to exacerbate asthma? Correct Answer- Metoprolol Tartrate( Lopressor) The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction. Pindolol (A) is a beta2 blocker that can cause broncho...

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction. - Answer: C It is likely that the f...

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