Exam (elaborations) 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.........................................................