Management of Care (#3)
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what prescription should the nurse request from the health care provider? You Selected: IV rate increase Correct response: IV rate increase Explanation: The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleed
LvL 6 to 7
A nurse is giving a shift report about a client in labor. Which of the following information is the least important to include to complete the report at the change of shift? You Selected: Bottle- or breastfeeding preference. Correct response: Bottle- or breastfeeding preference. Explanation: The bottle- or breastfeeding preference is the least important information to be reported to the oncoming shift. The bottle- or breastfeeding plans will be important after delivery as many mothers breastfeed within an hour after delivery. The client's obstetrical history is a higher priority because it provides information about previous birthing experience. Information on cervical effacement, dilation, and station indicates the current state of labor and is essential for planning continuity of care for this client. Nurses on the incoming shift should also know the extent of support the client will need and who is currently p
LvL 7 to 8
A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? You Selected: Discuss the unit's policy with the charge nurse. Correct response: Discuss the unit's policy with the charge nurse. Explanation: Because the nurse is new to the hospital, she should check with the charge nurse about the unit's visiting policy. The scenario doesn't provide information about whether the neonate's parents are married or if the mother is an emancipated minor. Therefore, the adolescent mother may not be able to legally make her own decisions about her parents' (the baby's grandparents') presence. She or her parents do have a say as to whether the father's parents can visit. The mother of the neonate does hav
LvL 0 to 1
A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? You Selected: Acute pain Correct response: Acute pain Explanation: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Impaired urinary elimination are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time. Add a Note Question 2 See full question 1m 18s The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to r
LvL 2 to 3
A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis? You Selected: "By discharge, the client correctly identifies three potassium-rich food sources." Correct response: "By discharge, the client correctly identifies three potassium-rich food sources." Explanation: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behavior. She should express that behavior in terms of client expectations and should indicate a time frame in which to accomplish it. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable outcomes. Understanding all complications of a disease process isn't measurable or sp
LvL 3 to 4
A staff nurse is caring for a client who is a potential heart donor. The client's family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process? You Selected: "I will have the transplant coordinator speak with you to answer your questions." Correct response: "I will have the transplant coordinator speak with you to answer your questions." Explanation: The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation process, typically speaks to family members about organ donation and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and
LvL 4 to 5
A nurse is using the computer when a client calls for pain medication. Which action by the nurse helps maintain computer security? You Selected: Logging out of the computer, then administering the pain medication Correct response: Logging out of the computer, then administering the pain medication Explanation: A nurse should meet a client's request for pain medication as quickly as possible after she logs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe computer practice. Add a Note Question 2 See full question 30s A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of
LvL 5 to 6
