When auscultating the respirations of a client in left ventricular heart failure, the nurse would most likely detect
a. crackling sounds.
b. diminished sounds.
c. grunting.
d. wheezing.
A
The client coughs because a large amount of fluid is trapped in the pulmonary tree, irritating the lung mucosa. On auscultation, bilateral crackles (rales) may be heard.
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To promote good skin care with the ICU elderly patient, a nursing intervention should include
A) using soap more frequently to eradicate the oils. B) using an emollient after bathing. C) limiting fluid intake to 1200 to 1500 cc daily. D) decreasing bathing time to every other day.
A 69-year-old patient is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial meningitis and admits the patient to the ICU
The nurse knows that risk factors for an unfavorable outcome include what? Select all that apply. A) Blood pressure greater than 140/90 mm Hg B) Heart rate greater than 120 bpm C) Older age D) Low Glasgow Coma Scale E) Lack of previous immunizations
Which assessment finding on the fetal monitor strip supports a diagnosis of abruptio placentae?
a. FHR of 150 bpm b. Moderate variability of FHR c. Contractions every 3 minutes d. Uterine resting tone of 30 mm Hg
The nurse is listening to a drug representative discuss receptorless drugs. Which drug choice made by the nurse as representing a receptorless drug would indicate a need for further teaching?
a. Antacids b. Antiseptics c. Saline laxatives d. Topical agents