The nurse is caring for a client in shock. Which of the following would be included in the nursing care plan? Select all that apply.
a. Assess electrolytes
b. Treat acidosis
c. Maintain systolic BP above 130
d. Maintain adequate tissue oxygenation
e. Maintain a patent airway
b. Treat acidosis
d. Maintain adequate tissue oxygenation
e. Maintain a patent airway
rationale: In managing the care of a client with shock, BP should be maintained at above 90 systolic, adequate tissue oxygenation should be maintained, acidosis should be treated and a patent airway maintained. The client should be kept warm.Acidosis occurs due to the lack of CO2 being blown off, so this must be treated.
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A prescriber has ordered deferasirox [Exjade] to treat iron overload associated with chronic blood transfusions. The nurse learns that the patient takes cholestyramine to reduce cholesterol
The nurse will contact the provider to request an order to: a. increase the cholestyramine dose. b. increase the deferasirox dose. c. monitor cholesterol levels. d. monitor liver function tests.
The nurse most effectively implements guided reminiscence during a patient interview by
a. reminding the patient to share important memories of the past. b. scheduling several short interviews rather than one long one. c. controlling the interview by selecting the memories to be discussed. d. encouraging the patient to relive his or her memories while maintaining focus.
A client has recently begun medication therapy with propranolol (Inderal). The long-term care nurse should plan to notify the physician if which of the following assessment findings is noted?
1. Complaints of insomnia 2. Audible expiratory wheezes 3. Decrease in heart rate from 86 to 78 beats/min 4. Decrease in blood pressure from 162/90 to 136/84 mm Hg
An outcome for a patient experiencing anticipatory grieving for a spouse diagnosed with terminal cancer would be that the patient will:
a. Continue to be emotionally involved with the dying spouse b. Develop protective mental mechanisms to allay the pain of spousal loss c. Not voice threats of physical violence that is either self or others directed d. Agree to stay at home and care for the spouse with appropriate assistance