A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal AV fistula in the RA. Which intervention should the nurse implement in caring for the client? SATA
a
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A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal AV fistula in the RA. Which intervention should the nurse implement in caring for the client? SATA
a. Assessing the radial pulse in the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA
d. Assessing the area over the AV fistula for a bruit and three each shift
e. Placing a pressure dressing over the site after each dialysis treatment
f. Administering IV fluids through the venous site of the AV fistula as needed correct answers A, B, C, D
A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which outcome does the nurse recognize as optimal respiratory outcomes for the client?
a. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias in the lower extremities
d. Clear sound in the lower lung fields bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg correct answers D, E
A nurse of the telemetry unit is caring for a client who has had a MI and is now attached to a cardiac monitor. The nurse is monitoring the client's cardiac rhythm and nots ventricular fibrillation. Which nursing intervention should the nurse take first?
a. Calling the rapid response team
b. Preparing the client for cardioversion
c. Asking the client to bear down and cough
d. Preparing to administer diltiazem correct answers A
The pattern of ventricular fibrillation is identified and can be a result after a patient with an MI. VF makes the patient feel faint, then loses consciousness and becomes pulseless and apneic (BP and heart sounds absent). Treatment is to terminate VF and covert it into a rhythm via defibrillation-> call a rapid and initiate CPR. Cardioversion is used for ventricular or supraventricular tachydysrhythmias.
A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate into the plan to prevent this complication?
a. Keeping the fan running in the client's room
b. Keeping the linens wrinkle free under the client
c. Limiting bladder catheterization to once every 12 hours
d. Avoiding the administration of enemas and rectal suppositories correct answers B
The most frequent cause of autonomic dysreflexias are a distended bladder and impacted feces. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize these risks.
A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further teaching?
a. I need to get more fluids and fiber into my diet
b. I should cut my food into small pieces before I eat
c. I need to put powder under the vest twice a day to prevent sweating
d. I have to check the pin sites everyday and watch for signs of infection correct answers C
Cleanse the skin under the wool liner each day to prevent rashes and soars.
A nurse is caring for a client with increased intracranial pressure. In which position should the nurse maintain the client?
a. Supine with the head extended
b. Side lying with the neck flexed
c. Supine with the head turned to the side
d. Head midline and elevated 30-45 degrees correct answers D
Proper positioning promotes venous drainage from the cranium to minimize ICP.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action first?
a. Asses the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze loosely in the ears
d. Use an otoscope to assess the tympanic membrane for rupture correct answers B
CSF contains glucose not protein.
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