After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis
Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which active physician order first? a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg.
b. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%.
c. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr.
d. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature > 101° F.
A
Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen. Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated.
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The daughter of a severely depressed patient asks the nurse "What do you think about the relationship between depression and physical illness? Since my mother has been grieving over my father's death, she has had colds, shingles, and the flu, and
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A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them
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A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?
a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution.
Why is it important for the nurse to understand the type of family that a client comes from? Select all that apply. Select all that apply
1. Family structure can influence finances and the ability to purchase nutritious foods. 2. Many types of families exist, and it is important to address the persons who hold power within the family. 3. The nurse can anticipate which problems a client will experience based on the type of family the client has. 4. Understanding if the client's family is nuclear or blended will help the nurse teach the client the appropriate information. 5. The values of the family will be predictable if the nurse knows what type of family the client is a part of.