EXAM 2 Questions

Shakiness and diaphoresis

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? Fever and chills Shakiness and diaphoresis Excessive thirst and urination Hypertension and crackles

Decreased deep tendon reflexes

A nurse is assessing a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia? Hypoactive bowel sounds Decreased deep tendon reflexes Cerebral edema Wheezing

Decreased circulation

A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors? Increased collagen Decreased circulation Increased muscle mass Decreased serum calcium

Sp02 and C02 monitoring

A nurse is assessing a client who received an opioid narcotic via a patient-controlled analgesia (PCA) for incisional pain. Which of the following findings is the priority? Sp02 and C02 monitoring Blood pressure and Fluid status Pain level and heart rate Level of sedation and mobility

Atelectasis

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? Pulmonary edema Atelectasis Delayed gastric emptying An upper respiratory infection

Respiratory acidosis

A nurse is caring for a client who has COPD. The nurse should identify the client is at risk for which of the following acid-base imbalances? Metabolic Acidosis Respiratory alkalosis Respiratory acidosis Metabolic alkalosis

Pneumonia

A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications? Pulmonary embolism Diarrhea Pneumonia Pressure injury

Metabolic alkalosis

A nurse is caring for a client who has nausea and is vomiting. The nurse should identify the client is at risk for which of the following acid-base imbalances? Respiratory acidosis ot SelectedRespiratory alkalosis Metabolic Acidosis Metabolic alkalosis

Attach a humidifier bottle to the base of the flow meter.

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? Apply petroleum jelly to the nares as needed to soothe mucous membranes. Attach a humidifier bottle to the base of the flow meter. Remove the nasal cannula while the client eats Secure the oxygen tubing to the bed sheet near the client's head.

Have the client breath into a paper bag.

A nurse is caring for a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take? Plan to administer sodium bicarbonate to the client. Have the client place their head between their knees. Plan to administer insulin to the client. Have the client breath into a paper bag.

Provide the client with a high-calorie diet.

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take? Elevate the head of the client's bed 55° Provide the client with a high-calorie diet. Massage the client's bony prominences. Reposition the client every 4 hr.

Delivers a low concentration of oxygen

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? Restricts the client's ability to eat, speak, or drink Delivers a low concentration of oxygen Delivers a high concentration of oxygen Delivers a constant rate of a specific concentration of oxygen

A client who is unresponsive to verbal commands and changes position occasionally.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury? A client who is receiving enteral feeding and can change position independently. A client who alert and responsive and eats 35% of each meal. A client who makes frequent slight changes in position and walks occasionally. A client who is unresponsive to verbal commands and changes position occasionally.

Dextrose 5% in water

A nurse is planning care for a client who has hypernatremia. Which of the following IV solutions should the nurse plan to initiate? Dextrose 5% in water Dextrose 10% in water Dextrose 5% in water 25% albumin Dextran 40

A client who has a new ankle sprain.

A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to utilize cold therapy? A client who has peripheral vascular disease. A client who is unconscious. A client who has a new ankle sprain. A client who has a spinal cord injury.

A nonrebreather mask should fit snugly over a client's face.

A nurse is teaching a newly licensed nurse about a nonrebreather oxygen mask. Which of the following instructions should the nurse include? A nonrebreather mask should fit snugly over a client's face. A nonrebreather mask dries a client's mucous membranes. The reservoir bag on a nonrebreather mask should collapse with exhalation. Use a nonrebreather mask to deliver low-flow oxygen.

Assign the patient to a room near the nurse's station. The patient should be placed near the nurse's station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore, a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.

A patient with new-onset confusion and hyponatremia is being admitted. Which action should the charge nurse take when making room assignments? Place the patient in a room nearest to the water fountain. Place the patient on telemetry to monitor for peaked T waves. Assign the patient to a room near the nurse's station. Assign the patient to a semiprivate room.

Oxygenation

After reviewing Amelia Adams record, what is your initial priority nursing intervention? Blood pressure Suicide Oxygenation Pain

PRIORITY Encourage Incentive Spirometer Notify MD for phosphorus replacement Administer Morphine Notify MD for potassium replacement Titrate oxygenation Notify MD for diuretic Orthostatic hypotension Saline lock IV fluids NON-PRIORITY Change IV site Hip Precautions in the chair Administer Tylenol Discharge patient Administer Ibuprofen Education regarding CHF

After reviewing the case, identify your priority nursing interventions. Please categorize all items.

The patient has hypokalemia and this condition may have symptoms such as muscle cramps.

Amelia Adams is complaining of muscles cramps in the back of her right leg. Which statement would indicate the RN is aware of the possible cause? The patient's hemoglobin and hematocrit are low and that is contributing to the muscle cramps. The patient has hypokalemia and this condition may have symptoms such as muscle cramps. The patient's sodium level is 135 and this will lead to muscle cramps. The patient has a calcium level of 9.0, that is contributing to the muscle cramps.

Amelia has hypokalemia, which means her potassium is low. This can cause weakness in her muscles. Amelia also has low hemoglobin levels and hematocrit, which means that she has less red blood cells. This can cause her to look pale.

Amelia Adams sons are at the bedside inquiring about why their mother is so weak and pale. As the nurse you are aware there are several reasons for the above. Please write a short response to the son's regarding their question.

Neuropathic

Described as intense, shooting, or burning. Patient may also describe the pain as numbness, "pins and needles," and even an intense itching (select the best answer that describes this pain) Nociceptive Neuropathic Cancer Pain Somatic

Isotonic: 0.9 Normal Saline Hypertonic: 3% Saline Hypotonic: 0.45% Normal Saline

Match the IV fluids to their category. Isotonic Hypertonic Hypotonic

(see picture)

Ms. Adams has been on bedrest for the past 3 days, refusing to turn. Identify the lesion that is of concern.

Chest physiotherapy

Please identify the following nursing intervention: enhances the clearance of secretions from the lungs through the use of external mechanical maneuvers. Pulmonary function test Gas diffusion test Chest physiotherapy Incentive spirometry

Kidney stones, constipation, hyperparathyroidism disease, pathological fractures

Please identify the signs and symptoms of hypercalcemia. Kidney stones, diarrhea, coughing, pathological fractures Vomiting, diarrhea, paralysis, pathological fractures Kidney stones, constipation, hyperparathyroidism disease, pathological fractures Tinnitus, vomiting, diarrhea, hyperactive reflexes Constipation, strong bones, hyperparathyroidism, kidney stones Constipation, hypothyroidism, pathological fractures, vomiting

Stage II

Please identify this pressure injury: Description: Loss of dermis presenting as a shallow open ulcer with a red pink wound bed or open/ruptured serum-filled blister. Stage III Stage II Stage I Stage IV

Stage III

Please identify this pressure injury: description full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue and epibole (rolled wound edges) is present. Stage I Stage III Stage IV Stage II

Air embolism: obstruction of a vessel by air Phlebitis: inflammation of the inner lining of the vein Central vein access: inserted into a centrally located vein Infiltration: medication or fluids move from the vein into the surrounding tissue

Please match the following definitions Air embolism Phlebitis Central vein access Infiltration

3% Normal Saline Fluid restriction

Please select treatment for hyponatremia (select all that apply) 3% Normal Saline Increase water intake Insulin Fluid restriction 10% Dextrose

hypernatremia Safe practice alert- prolonged use of normal saline results in hypernatremia and circulatory overload.

Prolonged use of normal saline can lead to _________________ and circulatory overload. (Please select the best answer) hypernatremia hypocalcemia hyperkalemia hypophosphatemia

Tachypnea Tachypnea is the most common sign to be found among patients with pulmonary embolism. Cough is not a sign of pulmonary embolism. Hemoptysis is not a sign of pulmonary embolism. Syncope is not a sign of pulmonary embolism.

The nurse assesses a patient for a possible pulmonary embolism. The nurse looks for the most frequent sign of: Headache Bradypnea Syncope Tachypnea

A patient who has not voided since the catheter was removed 8 hours ago Urinary retention is common after removal of urinary catheters and must be addressed promptly. The nurse should address the patient with urinary retention first because it is the highest priority. The other patients may wait until later.

The nurse is assigned to care for several patients on the surgical unit. Which patient need will the nurse address first? A patient who has not voided since the catheter was removed 8 hours ago A patient who is waiting for discharge teaching before going home A patient who needs to be ambulated for the first time postoperatively A patient who requires a daily dressing change to the surgical incision

Instruct the patient to always call for assistance before getting out of bed. The patient with hypercalcemia should always call for assistance before getting out of bed because of the risk of falling as a result of muscle weakness, soft bones, and lethargy. Diaphoresis and decreased urine output are not common symptoms of hypercalcemia. Teaching stress-relieving techniques is not a priority, especially since lethargy and stupor are symptoms of hypercalcemia.

The nurse is caring for a hospitalized patient with hyperparathyroid disease and a serum calcium level of 14.2 mg/dL. What is the priority intervention of the nurse? Measure urine output hourly and notify physician if urine output is less than 100 mL/hr. Measure urine output hourly and notify physician if urine output is less than 100 mL/hr. Instruct the patient to always call for assistance before getting out of bed. Teach stress-relieving techniques, including progressive muscle relaxation. Assist the patient to change into dry clothing after episodes of diaphoresis.

Dantrolene sodium (Dantrium) Malignant hyperthermia is a dangerous anesthesia reaction caused by a genetic defect that may be passed down via family history. Knowing this, the anesthesiologist would have dantrolene ready as a precaution because it is a mainstay of treatment for malignant hyperthermia. The other medications are not related.

The nurse is caring for a patient who has a family history of reactions to general anesthesia (malignant hyperthermia). Which medication will the nurse anesthetist have ready as a precautionary measure before the patient's surgery is started? Protamine sulfate Folinic acid (Leucovorin) Activated charcoal with sorbitol Dantrolene sodium (Dantrium)

The patient's lung sounds will remain clear. Oxygenation is the highest priority for the patient with congestive heart failure and fluid volume excess. Keeping the patient's lungs clear is the most important goal for the nurse to consider when caring for this patient.

The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis fluid volume excess in the patient's care plan. Which goal statement has the highest priority for the patient and nurse? The patient's lung sounds will remain clear. The patient will verbalize understanding of fluid restrictions. The patient will have a urine output of at least 10 mL/hr. The patient's pitting pedal edema will resolve within 72 hours.

Orthostatic hypotension The patient with dehydration is at risk for orthostatic hypotension, or falling of the blood pressure when the patient rises to a standing position. When the blood pressure falls sufficiently, fainting may occur. The patient should be assisted to rise slowly from a supine to a sitting position first before slowly getting to his feet.

The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. Which is the most likely cause of the patient's collapse? Hemolytic reaction Orthostatic hypotension Catheter embolism Circulatory overload

Perform regular neurologic checks and institute seizure precautions. A serum sodium level of 124 mEq/L is dangerously low and may cause neurologic problems including seizures, confusion, and weakness. Regular neurologic checks should be performed and the patient should be placed on seizure precautions until the sodium level is corrected. Encouraging the patient to eat high-sodium foods is fine, but it is not as important as the patient's safety. A hypotonic saline solution will further lower the patient's sodium level. Lanoxin toxicity is seen with hypokalemia rather than hyponatremia.

The nurse is caring for a patient who is admitted with a serum sodium level of 118 mEq/L. Which is the most important intervention for the nurse to perform? Na range: 135-145 mEq/L Perform regular neurologic checks and institute seizure precautions. Administer hypotonic IV solutions as ordered by the physician. Encourage the patient to eat foods that are high in sodium. Assess for signs and symptoms of digoxin (Lanoxin) toxicity.

Stop the blood transfusion and administer 0.9% normal saline through new IV tubing. A significant drop in blood pressure and a severe headache are signs that the patient may be experiencing a transfusion reaction. The transfusion should be stopped and 0.9% normal saline should be administered through new IV tubing to prevent infusion of additional blood through the tubing used for the transfusion. The physician should be notified immediately to evaluate the patient. Ensuring that the transfusion blood type is an exact match to the patient is done before the transfusion is begun.

The nurse is caring for a patient who is receiving a blood transfusion. One hour into the transfusion, the patient's blood pressure decreases significantly and the patient complains of a severe headache. What is the priority action of the nurse? Stop the blood transfusion and administer 0.9% normal saline through new IV tubing. Recheck the patient's blood pressure in 15 minutes after administering pain medication. Check the patient's temperature and administer acetaminophen (Tylenol) if higher than 101° F. Double-check that the transfusion blood type is an exact match to the patient.

The patient denies nausea or vomiting and states that he feels hungry. The patient's abdomen is soft with active bowel sounds x 4 quadrants. The patient passed flatus while ambulating this morning. The patient may indicate readiness for oral intake when passing flatus and relating feelings of hunger. The absence of nausea and vomiting along with active bowel sounds in a soft abdomen also indicate that the patient's GI tract is ready for oral feedings.

The nurse is caring for a patient who is recovering from bowel resection surgery. Which assessment findings indicate to the nurse that the patient no longer needs to remain NPO and may progress to oral intake of food and fluids? (Select all that apply.) The patient's abdominal incision is clean, dry, and intact with staples. The patient denies nausea or vomiting and states that he feels hungry. The patient's abdomen is soft with active bowel sounds x 4 quadrants. The patient ambulated in the hallway with a slow, steady gait. The patient's urinary catheter is patent with clear, yellow urine. The patient passed flatus while ambulating this morning.

The patient breathes into the spirometer so that the marker rises slowly. The patient must take in a deep breath while holding the spirometer to the mouth so that the device can indicate how much air is being inhaled into the lungs. The patient should use the spirometer at least 10 times every hour while awake, seal the lips closely around the mouthpiece, and rest for a few seconds between breaths.

The nurse is caring for a patient who is recovering from chest surgery. Which action by the patient indicates that additional teaching is needed about how to use the ordered incentive spirometer correctly? The patient seals his lips tightly around the spirometer mouthpiece. The patient uses the spirometer at least 10 times every hour while awake. The patient breathes into the spirometer so that the marker rises slowly. The patient rests for 5 to 10 seconds after each time the spirometer is used.

The patient had 1700 mL of light yellow urine in the last 24 hours. The goal that best indicates that the patient's dehydration has been corrected is output of 1300 mL of clear yellow urine in the last 24 hours. Dark concentrated urine is a symptom of dehydration. Jugular venous distention and presence of crackles in the lungs are both indicative of fluid volume overload.

The nurse is caring for a patient who is very dehydrated. Which goal best indicates that the nursing diagnosis of Deficient fluid volume has been corrected and that the patient's fluid balance has been restored? The patient's lung sounds are clear bilaterally. The patient has no jugular venous distention. The patient had 1700 mL of light yellow urine in the last 24 hours. The patient verbalizes need for adequate daily fluid intake.

True

Trousseau or Chvostek's signs may be present in hypocalcemia and Hypomagnesia? True False

The patient states that his abdominal pain is worse than yesterday. The patient's hematocrit dropped from 14.6 to 11.0 g/dL The patient's pulse has risen from 76 to 112 beats/min. Signs of internal bleeding include tachycardia, increased abdominal pain and a drop in hematocrit/hemoglobin. Urinary output would decrease with internal bleeding because the kidneys work to conserve fluids. Itching and constipation are not signs of internal bleeding.

The nurse is caring for a patient who underwent abdominal surgery the previous day. Which assessment findings indicate to the nurse that the patient may be experiencing serious internal bleeding? (Select all that apply.) The patient states that his abdominal pain is worse than yesterday. The patient's urinary output increased to 40 mL/hr. The patient's hematocrit dropped from 14.6 to 11.0 g/dL The patient has a normal bowel movement since surgery. The patient complains of generalized itching. The patient's pulse has risen from 76 to 112 beats/min.

pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L,

The nurse is caring for a patient who was brought to the ER after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect to see? Range PH: 7.35-7.45 PaC02: 35-45 HC03: 22-26 pH 7.35, PaCO2 45 mm Hg, HCO3 26 mEq/L, pH 7.56, PaCO2 32 mm Hg, HCO3 32 mEq/L pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, pH 7.45, PaCO2 38 mm Hg, HCO3 28 mEq/L,

The patient gives permission for the surgery to be performed. The patient's signature on the consent form indicates that the patient gives permission for the surgery to be performed. It does not indicate that the patient agrees with the physician's diagnosis, agrees to pay for costs not covered by insurance, or has been informed of all the possible treatment options.

The nurse is caring for a patient who will be having surgery. The patient has just signed the consent form for the operation. What does the patient's signature indicate? The patient agrees with the doctor's diagnosis. The patient has been told of all the available treatment options. The patient has agreed to pay for any costs not covered by insurance. The patient gives permission for the surgery to be performed.

Gastroenteritis with severe nausea, vomiting, and diarrhea Gastroenteritis with nausea, vomiting, and diarrhea will lead to a metabolic alkalosis resulting from loss of electrolytes and acids through emesis and loose stools. Metabolic alkalosis features the elevated pH of 7.56, elevated HCO3 42 mEq/L and normal PaCO2 of 32 mm Hg. Widespread tissue ischemia would lead to metabolic acidosis with low pH resulting from release of lactic acid from the tissues. Respiratory failure leads to a respiratory acidosis with a low pH and elevated PaCO2 level. Hyperventilation leads to respiratory alkalosis with an elevated pH and elevated HCO3 level.

The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 32 mm Hg, HCO3 49 mEq/L. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results? Range PH: 7.35-7.45 C02: 35-45 HC03: 22-26 Hyperventilation after a panic attack Widespread tissue ischemia caused by cardiogenic shock Respiratory failure caused by pneumonia with pleural effusions Gastroenteritis with severe nausea, vomiting, and diarrhea

"It's important to move around so you don't get a blood clot in your leg." The nurse should teach the patient why it is important to ambulate after surgery to prevent postoperative deep vein thrombosis (DVT) formation. Simply telling the patient that the physician ordered ambulation is not sufficient. Allowing the patient to stay in bed will increase the risk of DVT.

The nurse is caring for a postoperative patient on his first day after surgery. The nurse informs the patient that the plan is to sit in the chair and ambulate in the hallway. The patient states that he is in pain and he has no intention of getting out of bed. What is the nurse's best response? "I understand. You can rest in bed until tomorrow when the pain is better." "Your doctor ordered that you are to get out of bed at least twice every day." "It's important to move around so you don't get a blood clot in your leg." "I will call the doctor and let him know that you do not want to get up."

The patient will remain alert and oriented x3 with no confusion or seizure activity. A patient with low serum magnesium is at risk for neurologic symptoms including confusion, disorientation, and seizures. The highest priority goal for this patient is to avoid neurologic problems that could lead to injury. The other goals are applicable to the patient with low magnesium but are less important.

The nurse is caring for an ETOH (alcoholic) patient who has a serum magnesium level of 0.7 mEq/L. Which is the highest priority goal to include in the patient's plan of care? Range Mg: 1.8-2.2 The patient's oral mucous membranes will remain free of ulceration and pain. The patient will remain alert and oriented x3 with no confusion or seizure activity. The patient will verbalize the importance of sufficient dietary intake of magnesium. The patient will maintain urine output of at least 30 mL/hr.

The patient states that she has no pain. The best way for the nurse to determine that the pain medication was effective is for the patient to state that she has no pain. The other assessment findings cannot definitively determine whether or not the patient is still in pain.

The nurse is checking on the patient after administering pain medication 30 minutes previously. Which assessment finding best indicates to the nurse that the pain medication was effective? The patient is sleeping quietly. The patient's respirations are slow and regular. The patient states that she has no pain. The patient's blood pressure has returned to baseline.

Serum potassium level 6.8 mEq/L Normal serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 6.8 mEq/L is very high and puts the patient at risk for cardiac arrhythmias. The potassium level should be reported to the physician immediately.

The nurse is reviewing the patient's laboratory results. Which result must be communicated to the physician immediately? Serum sodium level 134 mEq/L Serum potassium level 6.8 mEq/L Serum magnesium level 2.3 mEq/L Serum chloride level 85 mEq/L

Assist the patient to the floor and call for assistance. The large red blood stain over the incision and feeling of ripping open most likely indicates that the patient's wound has dehisced or eviscerated. The nurse should immediately lower the patient to the floor to reduce tension on the wound. Patient modesty and privacy should be maintained, so the incision should be assessed once the patient is transported back to his room. Checking the patient's vital signs and pulse oximetry can be performed once the patient has been lowered to the floor.

The nurse is walking a postoperative patient in the hallway when she notices a large red stain of fresh blood on the patient's gown over the abdominal incision. The patient states, "I felt something just ripped open." What is the priority action of the nurse? Assist the patient to the floor and call for assistance. Return the patient to bed and irrigate the wound with sterile saline. Lift up the patient's gown and assess the incision. Check the patient's vital signs and pulse oximetry.

Applying TED hose and assisting with oral care. Provide ice chips and juice to patients who are no longer NPO. Empty urinary catheter bags and record urine output. Basic patient care tasks that do not require assessment or critical thinking may be assigned to the nursing assistant for completion. These include emptying drainage bags, providing ice chips to patients who are allowed oral intake, and applying TED hose. Teaching, monitoring, and assessing patients are done by the nurse.

The nurse is working with a nursing assistant to care for several postoperative patients. Which interventions can the nurse delegate to the assistant for completion? (Select all that apply.) Monitor incisions for signs of infection. Applying TED hose and assisting with oral care. Assess patients' comfort levels and need for pain medication. Teach patients how to use incentive spirometers hourly. Provide ice chips and juice to patients who are no longer NPO. Empty urinary catheter bags and record urine output.

True

The nurse knows that anxiety is a barrier to preoperative education (True or False). True False

The patient has generalized 3+ pitting edema. The patient's low albumin level will lead to generalized pitting edema because there isn't enough protein in the blood to keep water within the bloodstream. Lack of oncotic pressure from low serum albumin leads to edema.

The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient's albumin level is critically low. What assessment finding will the nurse expect to note when meeting with the patient? The patient's urine is dark and very concentrated. The patient is confused and disoriented. The patient lung sounds are very diminished. The patient has generalized 3+ pitting edema.

Dehiscence

You are caring for a patient 3 days status post abdominal surgery. It is time to perform a dressing change and when you remove the gauze you assess the following: partial opening of the incision with the remaining sutures present. You note there is no protrusion of abdominal content. Which definition best describes this assessment finding? Stage IV pressure injury Normal finding Dehiscence Evisceration

Splinting of abdomen to help with deep breathing and coughing

You are caring for a patient who has recently had an open laparotomy of the abdomen. The patient is hesitant to cough and deep breaths stating "it hurts too bad". After medicating with the prn pain medications, what intervention would be best to help this patient recover? Wait for the patient to move and take deep breaths on their own. Nothing- patient needs to rest. Splinting of abdomen to help with deep breathing and coughing Have the CNA teach the patient how to use the incentive spirometer

Oral replacement for potassium Oral replacement is recommended as the fastest way to improve K levels. IV replacement is recommended for patients who can't swallow or have anything by mouth. Kayexalate is given to treat hyperkalemia in some cases.

You are caring for a patient who will need potassium replacement. The current K is 2.9. Which of the following medications would be the best route for administration? IV replacement potassium over 6 hours Oral replacement with Kayexalate IV push 20 MEQ Potassium Oral replacement for potassium

Fluid volume excess

You are caring for a patient whose previous daily weight was 27kg. This morning's weight is 29kg and the patient has 2 plus pitting edema in bilateral lower legs along with crackles auscultated in the bases of their lungs. Which nursing diagnosis would be applicable? Dehydration Fluid volume excess Fluid volume deficit

Ensure a "Time-Out" is performed (before initiation of the procedure) Verify patient's name, date of birth, and allergies Ensure the patient has reduced injury (fall precautions, skin precautions, psychological injury)

You are working in preoperative and intraoperative today. Select the priority nursing interventions (select all that apply) Ensure a "Time-Out" is performed (before initiation of the procedure) Explain the pros and cons of the surgical procedure to the patient and family Verify patient's name, date of birth, and allergies Implement deep vein thrombosis prophylaxis (Sequential Compression devices and/or antithrombotic hoses) Ensure the patient has reduced injury (fall precautions, skin precautions, psychological injury) Patient with latex allergies- cancel the procedure Approve the route of anesthetic agents such as general, epidural, regional.