Exam 2 NR 341

1. The nurse is caring for a client with hypovolemic shock. The family member asks why the fluids are being warmed. What is the Best response by the nurse? “to prevent complications from hypothermia” 2. The nurse is caring for a newly admitted client diagnosed with acute kidney injury. The nurse understands that the acute kidney injury is Most likely related to a history of which condition? Sepsis 3. The nurse is caring for a client being monitored by arterial pressure monitoring. The nurse notes a systolic pressure of 164 mmHg. What action should the nurse take first ? Assess the client. 4. The nurse is caring for a client with an arteriovenous (AV) fistula. Upon assessment, the nurse is unable to auscultate a bruit. What action should the nurse take first? Notify the provider 5. The nurse is assessing jugular venous pressure. In what order should the nurse proceed with the steps in the process? [place the steps in the correct order beginning with the first step head of bed between 30-45 degrees. 2. Have client turn head slightly to the left. 6. Shine a pen light across the neck, assess for jugular venous distension at end of exhalation. ve the highest point of pulsation in the internal jugular vein at end exhalation. 4. Measure the vertical distance between the pulsation and the angle of louis. 1. Add 5 cm to the measurement. ......................................................................................CONTINUED