The nurse is assessing a client with lung disease. Which symptom does the nurse intervene for first?
a. The client's anterior-posterior chest di-ameter is 2:2.
b. Clubbing of the finger tips is noted.
c. The client has bilateral dependent leg edema.
d. The client is pale.
C
The client with bilateral dependent edema may be developing right-sided heart failure in response to respiratory disease. This symptom should be investigated right away and reported to the health care provider. Further assessment is needed. The client with chronic lung disease may develop increased anterior-posterior diameter and clubbing as responses to chronic hypoxia. These symptoms do not require immediate intervention. The client is often pale or has a dusky appearance; this also would not warrant immediate intervention.
You might also like to view...
A care aide at a long-term care facility has left a note for the care director stating that an 82-year-old resident has a grossly distended scrotum and a likely inguinal hernia
On examination, the resident has been diagnosed instead with hydrocele. What will the care team most likely tell the resident and his family about his diagnosis? A) "We'll get you to the hospital quickly, because if this isn't treated, it can result in a blockage in the blood flow to your testes." B) "This isn't a result of your intestine entering your scrotum, but an accumulation of fluid within your testes." C) "This can sometimes result from the lower level of sex hormones that comes with age, so you will likely benefit from a testosterone supplement." D) "While distressing to look at, this condition usually doesn't have any significant consequences and won't need treatment."
A client weighs 4.5 kilograms. How many pounds should the nurse document on the chart?
A) 2.4 B) 2.9 C) 9.4 D) 9.9
What instruction should be given to a client with decreased cardiac output from an old myocardial infarction who now needs to engage in a rehabilitation program after a total knee replacement?
A. "You must take prophylactic antibiotics just before engaging in the planned exer-cise." B. "You must take prophylactic nitroglycerin just before engaging in the planned exercise." C. "You must take prophylactic analgesics just before engaging in the planned exer-cise." D. "You must take prophylactic potassium chloride just before engaging in the planned exercise."
Which of the following characteristic does NOT involve a medical application of aspirin?
A. anti-inflammatory 1 B. antipyretic C. analgesic D. antihistaminic