1. What assessment findings should he nurse document in the electronic medical record for a client who is experiencing autonomic dysreflexia after a TANSWER-4 spinal cord injury ANSWER-Severe hyper... tension, diaphroresis, and flushing above the lesion 2. As the nurse is turning a client with a chest tube, the chest tube becomes dislodged from the pleural space. What action should the nurse take first? ANSWER-Have the client exhale forcefully and tape 3 sides of a sterile gauze over the insertion site 3. The nurse plans to administer a low dose prescription for dopamine (Intropin) to a client who is in septic shock. Which physiological parameter should the nurse use to evaluate a therapeutic response to dopamine? ANSWER-Urinary Output 4. The nurse assesses a male client postoperatively who has an arterial line in the radial artery. Assessment findings include pallor, parastesia, and slow capillary refill in the client’s right hand fingers. What action should the nurse plan? [Show More]
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