physiology

an older woman is brought to the emergency department. when caring for client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. which is the appropriate nursing response? 1) "I have a legal obligation to report this the of abuse." 2) "I promise I won't tell anyone, but let's see what we can do about this." 3) "Let's talk about ways that will prevent your daughter from hitting you." 4) "This should not be happening. if it happens again, you must call the emergency department"

"I have a legal obligation to report this type of abuse."

a client has a prescription to receive 1000ml of 5% dextrose in 0.45% sodium chloride. after gathering the approbate equipment, the nurse takes which action first before spiking the IV bag with tubing? 1) uncaps the distal end of the tubing 2 uncaps the spike portion of the tubing 3) opens the roller clamp on the IV bag 4) closes the roller clamp on the IV bag

closes the roller clamp on the IV bag

a client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. the client's activated partial thromboplastin (aPTT) time is 65 seconds. the licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed? 1) discounting the heparin infusion 2) increasing the rate of the heparin infusion 3) decreasing the rate of

leaving the rate of the heparin infusion as is the normal aPPT varies between 28 sec to 35 sec, depending on the type of activator used in testing. keep the aPPT between 1.5 and 2.5 times normal. IF within the range, and the dose should remain unchanged.

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? 1) vital signs 2) skin color 3) oxygen saturation 4) latest hematocrit level

vital signs a change in the vital signs may indicate that a transfusion reaction is occurring. the nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 nineties for the first half hour after beginning the transfusion and every half hour thereafter.