A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?
1. poor skin turgor
2. decreased urine output
3. distended neck veins
4. concentrated hemoglobin and hematocrit levels
Correct Answer: 3
Circulatory overload causes manifestations such as a full, bounding pulse; distended neck and peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit and blood urea nitrogen (BUN); and possible cerebral edema. The other answers indicate a fluid volume deficit.
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A nurse is collaborating with a team of community nurses to identify the vision and mission for community care. What is the central focus of community-based nursing?
A) Increased health literacy in the community B) Distributing ownership for the health of the community C) Promoting and maintaining the health of individuals and families D) Identifying links between lifestyle and health
The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques. Upon completion of the class, what should the nurse expect the participants to do?
A) Set goals for the next class session. B) Pass a written test on how to bathe a newborn infant. C) Review the major points of the class. D) Provide a return demonstration of a bath on a newborn doll.
A patient weighs 110 lb. Available is 25,000 units of heparin in 1000 mL of D5W. The physician orders a heparin sodium IV bolus of 80 units/kg and start the drip at 18 units/kg/hr. What is the heparin bolus dosage?
A) 900 units/hr B) 1000 units/hr C) 3900 units D) 4000 units
The nurse is giving you the shift report. She states the client's diagnoses, treatments, and course of hospitalization. When describing the client she states, "Whenever I try to teach him something, he becomes difficult and argumentative."
What client information about patient teaching should you ask? Select all that apply. a. Level of literacy b. Primary language c. Need for humor d. Level of anxiety e. Questions answered