A nurse is making ready to manage a transfusion of RBCs to a consumer who has coronary
heart failure. For which of the following manifestations ought to the nurse display to save you
fluid volume overload? (Select all that practice.)
A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension - ANSA. Dyspnea
C. Jugular vein distention
D. Confusion
Dyspnea is a medical manifestation of fluid extent overload. Jugular vein distention is a medical
manifestation of fluid quantity overload. Confusion is a scientific manifestation of fluid extent
overload.
A nurse is worrying for a patron who has a spinal cord injury and suspects the patron is
developing autonomic dysreflexia. Which of the subsequent moves have to the nurse take first?
A. Check the purchaser for a fecal impaction.
B. Examine the purchaser for areas of pores and skin breakdown.
C. Check the patron's bladder for distention.
D. Place the client in a sitting function. - ANSD. Place the purchaser in a sitting position.
The nurse must use the least invasive intervention first. Therefore, the nurse should region the
patron in a sitting function to decrease the manifestation of high blood pressure.
The nurse would possibly have to check the consumer for fecal impaction, that may precipitate
autonomic dysreflexia. However, the nurse have to use a much less invasive intervention first.
The nurse may need to have a look at the customer's skin for areas of pores and skin
breakdown or pressure, which could trigger autonomic dysreflexia. However, the nurse must
use a much less invasive intervention first. The nurse may have to check the client for bladder
distention, that could precipitate autonomic dysreflexia. However, the nurse ought to use a much
less invasive intervention first.
A nurse is teaching a newly certified nurse about the danger elements for dehiscence for
customers who've surgical incisions. Which of the subsequent elements must the nurse
encompass within the coaching? (Select all that follow.)
A. Poor nutritional state
, B. Altered intellectual popularity
C. Obesity
D. Pain medicinal drug management
E. Wound infection - ANSA. Poor nutritional country
C. Obesity
E. Wound infection
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical air flow.
Which of the following interventions should the nurse take to lessen the danger for
ventilator-associated pneumonia?
A. Position the top of the consumer's mattress inside the flat position.
B. Turn the client each 4 hr.
C. Rinse the consumer's mouth with an antimicrobial answer every 4 hr.
D. Perform hand hygiene prior to suctioning the patron's endotracheal tube. - ANSC. Rinse the
purchaser's mouth with an antimicrobial solution each 4 hr.
The nurse must brush the consumer's teeth every eight hr and rinse the patron's mouth with an
antimicrobial rinse every 2 hr to reduce the boom of micro organism.
The nurse ought to raise the head of the customer's mattress 30° to reduce the danger for
aspiration and pneumonia. The nurse must turn the purchaser each 2 hr to promote lung growth
and decrease the danger for pneumonia. The nurse need to perform hand hygiene prior to
suctioning the customer's endotracheal tube to lessen the threat of introducing micro organism.
A nurse is imparting practise to a new nurse approximately being concerned for clients who're
receiving diuretic therapy to treat coronary heart failure. The nurse need to provide an
explanation for that which of the subsequent medicinal drugs puts customers at chance for each
hyperkalemia and hyponatremia?
A. Furosemide
B. Hydrochlorothiazide
C. Metolazone
D. Spironolactone - ANSD. Spironolactone
Spironolactone is a potassium-sparing diuretic. It blocks the consequences of aldosterone in the
renal tubules, inflicting a loss of sodium and water and the retention of potassium. The possible
negative reactions include hyperkalemia and hyponatremia.
Furosemide is a excessive-ceiling (loop) diuretic that will increase the hazard of hyponatremia
and hypokalemia, not hyperkalemia. Hydrochlorothiazide is a thiazide diuretic that will increase
the chance of hypokalemia, not hyperkalemia. Metolazone is a thiazide diuretic that will increase
the chance of hyponatremia and hypokalemia, not hyperkalemia.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Legitexams. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.99. You're not tied to anything after your purchase.