HURST 11/7/21
A client with a history of alcoholism arrives at the clinic reporting severe abdominal pain with nausea and vomiting. What additional findings would make the nurse suspect the client may have pancreatitis?
Cullen's sign and tachycardia. Whether the client is experiencing acute or chronic pancreatitis, symptoms are severe and distinct. Bruising around the umbilicus is referred to as Cullen's Sign, indicating internal bleeding.
Which nursing interventions will help to prevent a contracture post-op in a client with a BKA?
Ensure the residual limb is positioned flat on the bed, position the client prone several times a day. We want the limb flat on the bed to prevent a contracture, the prone position will also stretch out any flexion that has occurred as a defensive withdrawal to muscle spasms.
A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first?
Increase the flow rate of the irrigation solution until the urine is a light pink. Continuous bladder irrigation is used following surgery to ensure that the bladder remains clear of blood clots, the nurse would need to increase the irrigation rate until the urine becomes light pink.
The nurse instructs a client taking isoniazid for the treatment of TB regarding appropriate food choices. Which food choices indicate to the nurse that teaching has been successful?
Pear salad with lettuce, foods high in tyramine can cause headaches, fast or irregular heartbeats, nausea, vomiting and sensitivity to light. Foods high in tyramine such as aged cheeses, certain meats, liver, fish, sour cream, raisins, bananas and avocados should not be eaten when taking isoniazid
A client with a diagnosis of embolic stroke is admitted to the medical unit. After 2 hours on the unit the client presents with agitation. Which nursing intervention would the nurse initially implement?
Place the client's neck in the midline position. The midline position will promote venous return to decrease cerebal blood volume and cerebral edema.