There are limited infusion pumps available on the nursing unit. Which client has the greatest need for accurate fluid monitoring? Select all that apply
A) Young adult with pneumonia
B) Adolescent with knee infection
C) Older adult receiving potassium chloride in the solution
D) Middle-aged adult receiving medication for congestive failure
C, D
Feedback:
A client with congestive failure should be monitored closely for signs of worsening fluid overload and is at great risk. Young adult and adolescent would need monitoring but not at greatest risk. Potassium chloride can cause extravasation if not monitored closely and is also at great risk.
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ANS:
A 55-year-old man with acute pancreatitis is being admitted. How can the critical care nurse best describe acute pancreatitis to the patient's family?
A) Toxic substances inflame the pancreas. B) The patient abuses alcohol. C) Viruses digest the pancreas. D) Pancreatic enzymes digest the pancreas.
The nurse is caring for a patient with cholelithiasis who has a new laboratory finding of serum amylase of 300 units/L. The patient states, "My primary health care provider said I don't have pancreatitis."
What is the most likely explanation for the laboratory finding? 1. The gallstone is causing acute cholecystitis. 2. The gallstone has migrated to the neck of the pancreas. 3. The gallstone has caused bile to back into the pancreas. 4. The gallstone is blocking the common bile duct.
When caring for a patient with an arm sling, the nursing assistant should do all of the following except
A) make the patient comfortable so he can wear the sling at all times. B) monitor the skin behind the neck for irritation and breakdown. C) monitor the skin under the arm for irritation and breakdown. D) wash the underarm and keep the area clean and dry.