The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy?
a. Normal body temperature
b. Balanced intake and output
c. Adequate pain management
d. Urine output of 0.5 mL/kg/hr
D
Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy. During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored.
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The nurse is changing an IV dressing on the premature newborn. The nurse uses care to:
A) apply plenty of tape, to assure the IV is secured in place. B) apply benzoin first, then apply plenty of tape, to ensure the IV is secured in place. C) apply the least amount of tape possible to secure the IV in place. D) apply benzoin, to make the dressing stick well.
It is important for the nurse to understand strategies that promote a fiscally responsible clinical practice. From the following listing, select those strategies that would achieve a fiscally responsible clinical practice. (Select all that apply.)
a. Completes charge slips or scans bar code of nursing supplies used when changing a surgical dressing b. Participates in the annual hospital fund-raising activity c. Visits the Centers for Medicare & Medicaid Services to understand what services are provided during an inpatient visit d. Immediately reports any development of a patient medical complication to the health care provider e. Volunteers to participate in a hospital program initiative to reduce central line associated bloodstream infection (CLABSI) f. Completes a patient's discharge plan on the morning of discharge
The nurse is performing an assessment on a client who thinks she may be experiencing preterm labor. Which information is the most important for the nurse to understand and share with the client?
a. Because all women must be considered at risk for preterm labor and prediction is so variable, teaching pregnant women the symptoms of preterm labor probably causes more harm through false alarms. b. Braxton Hicks contractions often signal the onset of preterm labor. c. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver. d. Diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change
The nurse is reviewing a patient's prescribed medications. Which medications are used to treat cancer by suppressing or blocking testosterone? (Select all that apply.)
a. Leuprolide (Lupron) b. Finasteride (Proscar) c. Dutasteride (Avodart) d. Diethylstilbesterol (DES) e. Goserelin (Zoladex)