The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?
a. Document the observation in the chart.
b. Measure urine specific gravity and vo-lume.
c. Assess the pulse and blood pressure.
d. Assess the client's deep tendon reflexes.
C
Neck veins in the normovolemic person are full in the supine position and flat in the sitting posi-tion. Full neck veins in the sitting position are an indicator of overhydration. Checking the pulse and blood pressure can help determine whether overhydration is present. Urine specific gravity is not as important a measure of volume status and deep tendon reflexes and does not give informa-tion on volume status at all. The nurse needs to document the finding, but interventions should not end there.
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The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?
a. "I get my chimney swept every other year." b. "My hot water heater is set at 120 degrees." c. "Sometimes I wake up at night and smoke." d. "I use a space heater when it gets below zero."
These comments are made by patients in a support group. Which comment best contributes to group cohesiveness and effectiveness?
a. "Talking about my problems helps me think of ways to solve them. Let me explain them to everyone." b. "We aren't making progress because our group leader has as many problems as we do." c. "No one in this group wants to hear anything else about your financial problems." d. "We started out talking about guilt, but we wandered off from that subject."
A nurse is initiating a 24-hour urine collection for a patient at home. What will be the first thing the nurse will ask the patient to do at the beginning of the specimen collection?
A) Void and discard the urine. B) Begin the collection at a specific time. C) Add the first voiding to the specimen. D) Keep the urine warm during collection.
When a patient is transferred to another unit, you must ensure that health care services are not ____________________.
Fill in the blank(s) with the appropriate word(s).