d. Skin tenting occurs when the client's forearm is pinched.
Give this one a try later!
5. An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding is the best indicator of hydration that the nurse should report to the
healthcare provider?
113. Why is it important for the nurse to monitor blood pressure in clients receiving
2
antipsychotic drugs?
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an
3
immediate investigation by the nurse?
, 18. The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and
4 scaly, and the mother reports that the child frequently scratches the lesions on the skin
to the point of causing bleeding. Which guideline is indicated for care of this child?
Don't know?
Terms in this set (160)
1. 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/hour IV. One hour after
admission to the unit, the
nurse notes 300 mL 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 finding to the
surgeon. Which action
should the nurse implement
first?
, 2. an adult male who fell 20 a. Add sterile water to the suction control chamber.
feet from the roof of this
home has multiple injuries,
including a right
pneumothorax. Chest tubes
were inserted in the
emergency department
prior to his transfer to the
intensive care unit (ICU). the
nurse notes that the suction
control chamber is
bubbling at the
- 10 cm H2O mark, with
fluctuation in the water seal,
and over the past hour 75
ml of bright red blood is
measured in the collection
chamber. Which
intervention should the
nurse implement?
3. A client who received c. Begin supplemental oxygen.
hemodialysis yesterday is
experiencing a blood
pressure of 200/100 mmHg,
heart rate 110 beats/minute,
and respiratory rate 36
breaths/minute. The client is
manifesting shortness of
breath, bilateral 2+ pedal
edema, and an oxygen
saturation on room air of
89%. Which action should
the nurse take first?
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