EAQ #3

The nurse is assessing a patient's smoking history. What does the nurse ask the patient who reports being a nonsmoker? Select all that apply. 1 .) "Have you ever smoked?" 2.) "Does anybody in your home smoke?" 3.) "Do you smoke when you are stressed?" 4.) "Do you have smokers among your friends?" 5 .) "Do you wake up from sleep with an urge to smoke?"

1 .) "Have you ever smoked?" 2.) "Does anybody in your home smoke?" 4.) "Do you have smokers among your friends?" To identify a patient's smoking history, the nurse should ask if the patient has ever smoked. The risk for cardiovascular disease (CVD) appears to be similar to that of a nonsmoker, 3 to 4 years after a person quits smoking. The nurse identifies if the patient is exposed to secondary smoke by asking if any family member or friend smokes. Passive smoke significantly reduces blood flow in a healthy young adult's coronary arteries, and the risk for dying increases among those who are exposed to secondhand smoke. When assessing a patient who does smoke, the nurse asks if the patient smokes when stressed and if the patient has the tendency to wake up from sleep with an urge to smoke.

The nurse is assessing an older adult patient with a neurologic disorder. Which questions does the nurse ask to test the patient's remote memory? Select all that apply. 1 .) "What is your date of birth?" 2.) "What is your current home address?" 3.) "What is the name of your health care provider?" 4.) "What are the names of the schools you attended?" 5.) "What is the name of the city where you were born?"

1 .) "What is your date of birth?" 4.) "What are the names of the schools you attended?" 5.) "What is the name of the city where you were born?" In order to test a patient's remote, or long-term, memory, the nurse should ask about anything from the past, such as the date or city of the patient's birth, or the names of schools that the patient attended. This information can be verified from either hospital records or by checking with other family members. Asking about the name of the patient's health care provider or present home address is beneficial to test the patient's recent memory.

A patient has come to the emergency department following a motor vehicle crash. In which order does the nurse perform the following actions to determine the patient's level of consciousness (LOC)?

1. Ask questions in a normal voice. 2. Ask questions in a loud voice. 3. Shake the patient gently. 4. Use painful or vigorous stimuli. In order to determine LOC, the nurse should first ask the patient some questions in a normal voice. It helps in determining if the patient is alert or lethargic. If the patient does not respond, then questions should be repeated in a loud voice. If there is no response, the nurse should then shake the patient gently. If patient is unresponsive, some vigorous or painful stimuli (e.g., supraorbital pressure, trapezius muscle squeeze) can be used. If patient does not respond to any of the stimuli, it suggests that the patient is unconscious and emergency interventions are needed.

A patient has undergone a single-photon emission computed tomography (SPECT). Which post-procedural instruction does the nurse give the patient? 1.) "Return to your usual activity." 2.) "Continue to use the ice pack." 3.) "Keep the head of the bed flat." 4.) "Call me if you have any itching."

1.) "Return to your usual activity." Patients who have undergone SPECT can return to their usual activities immediately after the test. Ice packs may be used by patients who have undergone cerebral angiography. Asking the patient to call if they have itching may be a typical instruction for a contact allergy, but not in this situation. The head of the bed should be kept flat for patients who have undergone a lumbar puncture.

The nurse is teaching a patient about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? 1.) "This test evaluates you for potentially fatal cardiac rhythms." 2.) "This is a noninvasive test performed to assess your heart rhythm." 3.) "This is a painless test that is done to assess the structure of your heart using sound waves." 4.) "You will receive an injection of dobutamine and will walk on a treadmill to reveal whether you have coronary artery disease."

1.) "This test evaluates you for potentially fatal cardiac rhythms." Electrophysiology studies (EPS) are invasive tests performed to determine whether the patient has lethal dysrhythmias and conduction abnormalities. A noninvasive test to assess the heart rhythm best describes the electrocardiogram (ECG). Injection of dobutamine followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography.

The nurse is assessing the cerebral motor integrity of a patient with muscle weakness. Arrange the steps of the assessment in the order in which they are performed.

1.) Ask the patient to close the eyes. 2.) Hold the arms perpendicular to the body. 3.) Keep the palms up for 15 to 30 seconds. 4.) The arm on the weak side falls with the palm pronating. The patient is first asked to close the eyes. Then the arms are held perpendicular to the body with the palms up for 15 to 30 seconds. The arm on the weak side falls with the palms pronating or turning inwards. This pronator drift is caused when there is a cerebral or brainstem problem affecting the muscles.

The nurse is working with a student nurse performing a neurological assessment. Which action by the student nurse requires intervention? 1.) Increasing the room light before testing pupil reaction 2.) Determining orientation by asking the patient the year and month 3.) Measuring hand strength by having the patient squeeze the student's fingers 4.) Observing lower extremity movement by requesting the patient to kick out each leg

1.) Increasing the room light before testing pupil reaction Pupil reaction is assessed after dimming, not brightening, the lights or having the patient close and then open the eyes. Orientation can be assessed by asking questions like the date, the address of the patient, or the name of the health care facility the patient is visiting. Upper extremity strength can be assessed with finger grips, and lower extremity movement can be assessed through movement of the legs and feet.

The nurse assesses peripheral pulses and auscultates the patient's heart and lungs before a cardiac catheterization test for a patient suspected to have valvular dysfunction. Which other intervention should the nurse implement before the procedure? 1.) Instruct the patient to withhold any medication for diuretics therapy. 2.) Administer steroids if the patient has contrast-induced renal toxicity. 3.) Administer acetylcysteine if the patient has an allergy to iodine-based contrast agents. 4.) Instruct the patient to withhold medication if the patient is on calcium channel blockers.

1.) Instruct the patient to withhold any medication for diuretics therapy. The nurse should instruct the patient to withhold any diuretic or digitalis medications before the procedure to minimize the effect on catheterization. If the patient has an allergy to iodine-based contrast agents, the nurse should administer steroids. The nurse should administer acetylcysteine if the patient has contrast-induced renal toxicity. The nurse should instruct the patient to withhold medication if the patient is on calcium channel blockers therapy.

The nurse is performing an admission assessment for a patient scheduled to undergo a coronary arteriogram. Which symptom, if reported to the nurse, would be most important to be passed on to the provider prior to the procedure? 1.) The patient develops wheezes and dyspnea after eating crab or lobster. 2.) The patient has had intermittent substernal chest pain for 6 months. 3.) The patient reports that a previous arteriogram was negative for coronary artery disease. 4.) The patient has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.

1.) The patient develops wheezes and dyspnea after eating crab or lobster. The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the patient with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure. The reason the patient is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain; the intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time; it is nice to know, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure; they can be assessed with a Doppler and marked in ink. Therefore, this information is not needed before the procedure is performed.

The nurse is assessing a patient with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? 1.) Validate that the patient has remained NPO. 2.) Reassure the patient that the test is painless. 3.) Teach the patient about the reason for the TEE. 4.) Auscultate the patient's precordium for murmurs.

1.) Validate that the patient has remained NPO. Owing to the risk for aspiration, the patient must be NPO before the procedure. It is anticipated that the patient with mitral stenosis may have an audible murmur; this action is not essential at this time. Although teaching is important, the patient could undergo the procedure without understanding the reason for the test. The patient will have sedation during the test because it is uncomfortable.

The nurse has just received report on a group of patients. Which patient does the nurse assess first? 1.) Older adult who has expressive aphasia after a left-sided stroke 2.) Adult who had a cerebral arteriogram and has a cool, pale right leg 3.) Middle-aged adult who has a headache after undergoing a lumbar puncture 4.) Young adult who was in a car accident and has a Glasgow Coma Scale score of 13

2.) Adult who had a cerebral arteriogram and has a cool, pale right leg A cool, pale leg after an arteriogram could indicate clot formation at the catheter insertion site and loss of blood flow to the extremity. The patient with a 13 GCS score, the patient with a headache following a lumbar puncture, and the older adult with expressive aphasia should be assessed as soon as possible, but the data do not indicate any serious complications.

What does the nurse anticipate finding during the assessment of an electrocardiogram (ECG) in an older adult? 1.) Junction rhythms 2.) Atrial dysrhythmias 3.) Ventricular tachycardia 4.) Narrowed QRS complexes

2.) Atrial dysrhythmias The nurse can anticipate finding atrial dysrhythmias during the assessment of an ECG in an older adult. These can occur due to the conduction system changes that occur with aging. Ventricular tachycardia, junction rhythms, and narrowed QRS complexes are not anticipated findings during an ECG assessment in an older adult.

According to the New York Heart Association Functional Classification of Cardiovascular Disability, which class includes patients with symptoms of fatigue, palpitations, dyspnea, and angina even after ordinary physical activities? 1.) Class I 2.) Class II 3.) Class III 4.) Class IV

2.) Class II According to the New York Heart Association Functional Classification of Cardiovascular Disability, class II includes patients with symptoms of fatigue, palpitation, dyspnea, or angina even after ordinary physical activities. Class I includes patients who do not face fatigue, palpitation, dyspnea, or angina after ordinary physical activities. Class III includes patients who complain of palpitation, dyspnea, or angina after less than ordinary physical activity. Class IV includes patients who complain of increased discomfort after conducting any form of physical activity.

The results of a patient's cerebral spinal fluid analysis have been obtained. Which results does the nurse identify as normal? Select all that apply. 1.) Glucose 25 mg/dL 2.) Lactic acid 20 mg/dL 3.) Total protein 75 mg/dL 4.) Color is clear or colorless 5.) Less than 5 lymphocytes/mm 2

2.) Lactic acid 20 mg/dL 4.) Color is clear or colorless 5.) Less than 5 lymphocytes/mm 2 Normal cerebral spinal fluid is clear and colorless, and contains 0-5 lymphocytes/mm 2, 15-45 mg/dL of protein, 50-75 mg/dL of glucose, and 10-25 mg/dL of lactic acid.

The nurse is assessing a patient who reports an inability to sleep well at night due to difficulty breathing. The patient usually uses two pillows and at times requires an extra pillow to promote sleep. How does the nurse document this finding? 1.) Fatigue 2.) Orthopnea 3.) Dyspnea on exertion (DOE) 4.) Paroxysmal nocturnal dyspnea (PND)

2.) Orthopnea These signs and symptoms describe orthopnea. The patient is experiencing dyspnea upon lying flat and several pillows are used to elevate the head and chest. The severity of orthopnea is measured by the number of pillows or amount of head elevation needed for restful sleep. This symptom is relieved by sitting or standing. Fatigue is described as a feeling of tiredness resulting from activity; fatigue that occurs after mild activity or exertion indicates inadequate cardiac output. Dyspnea associated with activity such as climbing stairs is referred to as dyspnea on exertion (DOE). Paroxysmal nocturnal dyspnea (PND) develops after the patient has been lying down for several hours and then awakens abruptly, often with a feeling of suffocation and panic. This is relieved by sitting up and dangling the legs over the side of the bed.

A patient on a telemetry unit is scheduled for electrophysiologic studies (EPS). Which condition does the patient likely have? 1.) Pericarditis 2.) Post-sudden cardiac arrest 3.) Allergy to intravenous contrast 4.) Episode of acute coronary syndrome

2.) Post-sudden cardiac arrest Electrophysiologic studies are performed for patients who experience sudden cardiac arrest or ventricular dysrhythmia. Pericarditis may be diagnosed with WBC count, ESR, and ECG. ACS is diagnosed with enzyme and cardiac markers and ECG. Allergies are reported by the patient or a member of the health care team after observing the allergic reaction.

The nurse is reviewing the medical record of a patient admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? 1.) Calcium 8.5 mEq/L 2.) Potassium 3.0 mEq/L 3.) Magnesium 2.1 mEq/L 4.) International Normalized Ratio (INR) of 1.0

2.) Potassium 3.0 mEq/L Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the patient is taking digitalis preparations. A normal calcium level is 8.5 to 10.5 mEq/L. A normal magnesium level is 1.7 to 2.4 mEq/L. INR of 1.0 reflects a normal value.

A 72-year-old patient admitted with fatigue and dyspnea has elevated white blood cell count, low-density lipoproteins, serum troponin I level, and C-reactive protein. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? 1.) C-reactive protein 2.) Serum troponin I level 3.) Low-density lipoproteins 4.) White blood cell (WBC) count

2.) Serum troponin I level Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications. The white blood cell count does not reflect acute coronary syndrome; a mild leukocytosis may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of acute coronary syndrome, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem.

A patient reports to the nurse, "I have a sharp, stabbing pain that usually spreads to my left side or my back and is relieved when I sit upright. It tends to come and go." How should the nurse interpret this concern? 1.) The patient has angina. 2.) The patient has pericarditis. 3.) The patient has valvular dysfunction. 4.) The patient has myocardial infarction.

2.) The patient has pericarditis. The presence of intermittent sharp, stabbing pain that usually spreads to the left side or the back and is relieved when sitting upright indicates symptoms of pericarditis. Squeezing, viselike pain usually on the left side of the chest without radiation, lasting for less than 15 minutes and relieved by rest indicates angina. The presence of fluttering, racing, or irregular heartbeat, and symptoms of dizziness and fainting indicates valvular dysfunction. Continuous intense stabbing, viselike pain that may spread throughout the anterior chest and to the arms, jaw, back or neck that are relieved with morphine and cardiac drugs indicates myocardial infarction.

What actions does the nurse perform to assess the sensory function of a patient with a spinal cord problem? Select all that apply. 1.) The patient keeps the eyes open during the test. 2.) The patient is shown the object before the assessment. 3.) A cold reflex hammer is used to distinguish temperature. 4.) The patient identifies sharp and dull touch in random sequence. 5.) Two places on the same extremity are touched with two objects.

2.) The patient is shown the object before the assessment. 3.) A cold reflex hammer is used to distinguish temperature. 4.) The patient identifies sharp and dull touch in random sequence. 5.) Two places on the same extremity are touched with two objects. The sensory function assessment is done to assess the patient's sensation of pain and temperature. A cold reflex hammer or a warm hand is used to distinguish temperature. The patient is asked to identify the touch of a sharp object such as a paper clip and the touch of a dull object such as a cotton-tipped applicator. The patient is shown the object before the assessment begins, so that the patient is aware of the object. The nurse tests the touch discrimination in a patient by touching two places on the same extremity with two objects at the same time. The patient is asked to identify the locations that were touched. During the test, the patient is expected to close the eyes and identify the location and object that was used.

In assessing a patient's cerebellar function, what does the nurse ask the patient to do to assess gait? 1.) Stand on one foot, then on the other. 2.) Walk across the room, turn, and return. 3.) Run the heel of one foot down the shin of the other leg. 4.) Stand with arms at the side, feet and knees close together.

2.) Walk across the room, turn, and return. The nurse assessing the gait of a patient for problems with cerebellar function asks the patient to walk across the room, turn, and return. The patient is observed for uneven steps and difficulty in walking. The patient stands on one foot then on the other to evaluate balance. The patient stands with arms at the side, feet and knees close together, and eyes open to test for swaying; if the patient sways with the eyes open and closed, it indicates presence of neurological disturbance of cerebellar origin. The patient runs the heel of one foot down the shin of the other leg to assess fine coordination of muscle activity.

The nurse has just received report on a group of patients on the neurosurgical unit. Which patient is the nurse's first priority? 1.) Adult whose deep tendon reflexes have become hyperactive 2.) Young adult whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10 3.) Middle-aged adult who displays plantar flexion when the bottom of the foot is stroked 4.) Older adult who consistently demonstrates decortication when stimulated

2.) Young adult whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10 The change in the young patient's GCS rating indicates a significant change in neurologic status that should be immediately assessed further and reported to the health care provider. The patient with hyperactive reflexes, the patient displaying plantar flexion when the bottom of the foot is stroked, and the patient with decortication upon stimulation will need to be assessed, but the changes in their conditions do not require immediate attention.

The nurse is caring for a patient exhibiting symptoms of dementia. The patient's condition is deteriorating. Which nursing interventions are the nurse's priority? Select all that apply. 1 .) Recommending physical exercise. 2 .) Instructing the patient to follow a nutritious diet. 3 .) Ensuring the patient's bedroom is quiet at night. 4 .) Employing memory aids like using alarms and notes. 5 .) Helping the patient stay on a regular sleep schedule.

3 .) Ensuring the patient's bedroom is quiet at night. 5 .) Helping the patient stay on a regular sleep schedule. Lack of sleep may worsen the symptoms of dementia, so promoting a good sleep environment is the priority intervention that can help the patient. Two ways to do this are to ensure the patient's bedroom is quiet at night and helping the patient go to bed and wake up at the same time every night and day. Physical exercise, the use of memory aids, and healthy diet are helpful interventions but can be undertaken after the patient is better rested.

The nurse is preparing the patient for an echocardiogram. Which point reflects correct patient teaching before the procedure? 1.) "You must not eat or drink anything for 8 hours before the test." 2.) "You will need to drink a contrast dye 1 hour before the procedure." 3.) "The technician will put lubricant on a transducer and rub this on your chest." 4.) "After the technician injects you with a radioisotope, you will be asked to exercise a few additional minutes.

3.) "The technician will put lubricant on a transducer and rub this on your chest." An echocardiogram is a noninvasive ultrasound procedure to view the cardiac structures; a transducer lubricated with gel is rubbed over the chest. This test does not require anesthesia or sedation; therefore, the timing of a meal is not essential for patient safety. A myocardial nuclear perfusion imaging test involves walking on a treadmill or injecting a chemical which simulates exercise, followed by the injection of a radioisotope to assess myocardial perfusion. Contrast media, via IV or oral route, is not used for an echocardiogram.

Which patient does the neurologic unit charge nurse assign to a registered nurse (RN) who has floated from the labor/delivery unit for the shift? 1.) Older adult patient who was just admitted with a stroke and needs an admission assessment 2.) Young adult patient who has had a lumbar puncture and reports, "Light hurts my eyes." 3.) Adult patient who has just returned from having a cerebral arteriogram and needs vital signs checks every 15 minutes 4.) Middle-aged patient who has a possible brain tumor and has questions about the scheduled magnetic resonance imaging

3.) Adult patient who has just returned from having a cerebral arteriogram and needs vital signs checks every 15 minutes An RN with experience in labor and delivery would be able to check vital signs and limbs for the adult patient following cerebral arteriogram and would recognize signs of bleeding. The older adult admitted with a stroke, the young adult post-lumbar puncture, and the middle-aged patient with a possible brain tumor all require a nurse with more experience with neurologic diagnoses and diagnostic procedures. These patients should be assigned to a nurse with experience on the neurologic unit.

Which action should the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? 1.) Assess preprocedure medications the patient took that day. 2.) Obtain patient vital signs and a resting electrocardiogram (ECG). 3.) Have the patient sign the consent form before the procedure is performed. 4.) Educate the patient about the need to remain on bedrest after the procedure.

4.) Educate the patient about the need to remain on bedrest after the procedure. Vital signs and 12-lead ECGs can be assessed by UAP. The health care provider will explain the catheterization procedure and have the patient sign the consent form. Assessments and patient teaching should be done by the RN.

The nurse has just received change-of-shift report about a group of patients on the neurosurgical unit. Which patient would the nurse see first? 1.) Young adult patient involved in a motor vehicle crash (MVC) who is yelling obscenities at the nursing staff 2.) Adult postoperative left craniotomy patient whose hand grips are weaker on the right 3.) Middle-aged adult patient who had a cerebral aneurysm clipping and is increasingly stuporous 4.) Older adult patient who had a carotid endarterectomy and is unable to state the day of the week

3.) Middle-aged adult patient who had a cerebral aneurysm clipping and is increasingly stuporous Change in level of consciousness (LOC) is an early indication that central neurologic function has declined; the neurologic status of the middle-aged adult patient would be assessed first and the health care provider notified about the change in status. The other patients are not the nurse's first priority. The young adult who is post-MVC does need to be assessed, but the patient's behavior does not indicate a decline in neurologic function. The postoperative left craniotomy patient and the older adult do need to be assessed, but these patients' neurologic assessment indicates better function.

The health care provider orders an electroencephalogram (EEG) for a patient who may have a sleep disorder. Which teaching will the nurse provide before the test? 1.) Fast for six hours before the test. 2.) Avoid sleeping in a prone position. 3.) Sleep less the night before the test. 4.) Avoid alcohol and tobacco 36 hours before the test.

3.) Sleep less the night before the test. The nurse might advise the patient to sleep less the night before an electroencephalogram (EEG) so that the test is more effective in determining sleep disorders. The patient can sleep in a prone position; this won't affect the test. The patient should not fast before the test because hypoglycemia may alter the recording. Sedatives and stimulants should be avoided for 12-24, not 36, hours before the EEG.

A Glasgow Coma Scale is ordered on a patient. The nurse observes these signs and symptoms upon initial assessment: opens eyes to sound; localizes pain; confused conversation. Which number would the nurse record as this patient's Glasgow Coma Scale score? 1.) 8 2.) 15 3.) 13 4.) 12

4.) 12 The patient's Glasgow Coma Scale score is 12 because the patient receives 3 points for opening eyes in response to sound out of a possible 4, a score of 5 on motor response to localized pain out of a possible 6, and a score of 4 for verbal response of confused conversation out of 5. To score 15, the patient must respond with no deficiencies. A score of 8 would represent a near coma state. A score of 13 would indicate a minor change from one of the assessed parameters stated.

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of patients. Which patient is appropriate for the RN to assign to the LPN/LVN? 1.) A patient with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures 2.) A patient with acute coronary syndrome who has just been admitted and needs an admission assessment 3.) A patient who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging 4.) A patient who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index

4.) A patient who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and lower extremity. The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing patient education; the LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care; the LPN/LVN may implement the plan.

A nurse is teaching a patient scheduled to undergo an electroencephalogram (EEG). Which action of the patient implies a good understanding about the instructions? 1.) Does not wash the hair before the test 2.) Takes central nervous system stimulants before the test 3.) Takes central nervous system depressants before the test 4.) Avoids any caffeine-containing beverages on the day of the test

4.) Avoids any caffeine-containing beverages on the day of the test Caffeine-containing fluids should be avoided as they may interfere with the test results. The patient's hair should be thoroughly washed with shampoo and water to avoid false results due to contamination. Central nervous system stimulants and depressants must be avoided; these agents alter brain activity and lead to incorrect information.

A patient with heart failure reports a 7.6-lb weight gain in the past week. What intervention does the nurse anticipate from the health care provider? 1.) Dietary consult 2.) Restricted activity 3.) Sodium restriction 4.) Daily weight monitoring

4.) Daily weight monitoring A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight . It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent. The weight change is most likely from excessive fluid so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions.

Which information is most important for the nurse to communicate to the health care provider about a patient who is scheduled for cerebral angiography? 1.) Allergy to penicillin 2.) History of bacterial meningitis 3.) The patient's dose of metformin held today 4.) Poor skin turgor and dry mucous membranes

4.) Poor skin turgor and dry mucous membranes An assessment of poor skin turgor and dry mucous membranes indicates dehydration; to prevent contrast-induced nephropathy, angiography should not be done until the patient is hydrated. Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported, but none indicate the need to intervene before the surgery.

In assessing a patient who is unconscious, what care does the nurse take when applying painful stimuli using the sternal rub? 1.) Apply the sternal rub for not more than a minute. 2.) Avoid the use of the sternal rub in younger patients. 3.) Avoid stimuli if the patient does not respond to supraorbital pressure. 4.) Use the sternal rub if the patient does not respond to mandibular pressure.

4.) Use the sternal rub if the patient does not respond to mandibular pressure. The sternal rub should be used when the patient does not respond to mandibular pressure. Sternal rub is not applied for more than 20 to 30 seconds and is not applied to older adults or patients who bruise easily because the tissue in the area of the sternum is tender and bruises easily. The nurse should first apply supraorbital pressure to determine response to painful stimuli. If the patient does not respond, a trapezius muscle squeeze should be attempted. On failure to respond to this, the nurse applies mandibular pressure. The sternum rub is the last effort to obtain response to painful stimuli.