The nurse assumes care of A. Assess for signs of fluid volume deficit
a postoperative adult
client with type 2 diabetes
mellitus and learns that
the client has a current
blood glucose level of
720 mg/dL. When
assessing the client, what
is the priority?
A. Assess for signs of fluid
volume deficit
B. Observe wound
drainage characteristics
C. Measure the level of
acute pain
D. Determine when the
client last ate
A male client tells the A. Encourage the client to obtain a complete physical
nurse that he is concerned exam, since these symptoms are consistent with an
that he may have a ulcer
stomach ulcer, because he
is experiencing heartburn
and dull gnawing pain that
is relieved when he eats.
Which is the best
response by the nurse?
A. Encourage the client to
obtain a complete
physical exam, since these
symptoms are consistent
with an ulcer
B. Assure the client that his
symptoms may only
reflect reflux, since ulcer
pain is not relieved with
food
C. Instruct the client that
these mild symptoms can
generally be controlled
with changes in his diet
D. Advise the client that he
needs to seek immediate
medical evaluation and
treatment of these
symptoms
A male client with D. Increase the infusion rate of Lactated Ringer's
stomach cancer returns to solution
the unit following a total
gastrectomy. He has a
nasogastric tube to
suction and is receiving
Lactated Ringer's solution
at 75 mL/hr IV. One hour
after admission to the unit,
the nurse notes 300mL of
blood in the suction
canister, the client's heart
rate is 155 beats/minute,
and his blood pressure is
78/48 mmHg. In addition
to reporting the findings
to the surgeon, which
action should the nurse
implement first?
A. Measure and document
the client's urinary output
B. Request the client's
reserved unit of packed
red blood cells
C. Prepare for placement
of a central venous
catheter
D. Increase the infusion
rate of Lactated Ringer's
solution
A heparin infusion is -1st: calculate the weight = 220/2.2= 100kg
prescribed for a client -Then calculate total dose in units = 18units x 100kg =
who weighs 220 pounds. 1800 units/hr
After administering a - 25000 units - in 250
bolus dose of 80 units/kg, 1800 units ---in X ml
the nurse calculates the x = 1800 x 250/25000 =18 mL/hr
infusion rate for the
heparin solution as 18
units/kg/hour. The
available solution is
Heparin Sodium 25,000
Units in 5% Dextrose
Injection 250 mL. The
nurse should program the
infusion pump to deliver
how many mL/hour?
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