The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should:
a. prepare to assist with a routine dialysis catheter change to replace the existing catheter.
b. evaluate the patient for signs and symptoms of infection.
c. teach the patient that the catheter is designed for long-term use.
d. use one of the three lumens for fluid administration.
B
Routine replacement of hemodialysis catheters to prevent infection is not recommended. The decision to remove or replace the catheter is based on clinical need and/or signs and symptoms of infection. The typical catheter has a single or double lumen and is designed only for short-term renal replacement therapy during acute situations. The catheter is not used for fluid and medication administration.
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The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?
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A client recovering from surgical repair for a compound fracture of the leg is confused to place and time and the left side of the face is drooping. The nurse should conclude that the client:
1. is experiencing a fat embolism to the brain. 2. has a deep vein thrombosis. 3. has pulmonary edema. 4. is hemorrhaging on the brain.
The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action?
a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.
The finding of which of the following conditions in a client complaining of uterine contractions would lead the nurse to determine that the client is in true labor?
A) Decrease in vaginal secretions B) Change in contraction with activity C) Rupture of amniotic membranes D) Decrease in duration of contractions