The nurse is managing the care of a patient receiving PN. Which assessment finding indicates potential septicemia?
a. Shakiness and dizziness
b. Chest pain/hypotension
c. Increased thirst
d. Increased temperature
D
Know the patient's recent temperature range. Patients with peripheral or central intravenous (IV) lines are susceptible to septicemia; elevated temperature can be an early indicator of a bacterial process. Hypoglycemia causes the patient to be shaky, dizzy, nervous, and anxious; the patient senses hunger and has a blood sugar level less than 80 mg/100 mL. Air embolism results in sudden respiratory distress, shortness of breath, coughing, chest pain, and decreased blood pressure. Hyperglycemia leads to excessive thirst.
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The results of an older patient's urinalysis reveal bacteria in the urine. What action should the nurse perform next?
1. Notify the physician. 2. Order a repeat urinalysis to confirm the initial test. 3. Order a culture and sensitivity to identify the exact type of bacteria. 4. Review the nursing assessment for reports consistent with a urinary tract infection.
The nurse is discussing storage of breast milk with a mother whose infant is preterm and in the special care unit. Which statement would indicate that the mother needs additional teaching?
a. "I can store my breast milk in the refrigerator for 3 months." b. "I can store my breast milk in the freezer for 3 months." c. "I can store my breast milk at room temperature for 8 hours." d. "I can store my breast milk in the refrigerator for 3 to 5 days."
What is the primary concern for the parents of a dying child?
a. Pain b. Safety c. Food intake d. Fluid intake
A client has chosen to discontinue hemodialysis. His family is not supportive of his decision. The nurse who uses the theory of principles-based reasoning would make which of the following statements?
1. "This client is of sound mind and is capable of making his own decisions regarding health care. It really is his decision to make." 2. "I need to try and help the family understand the client's decision so they can work through this situation together." 3. "This client's health is so deteriorated that the treatment is not saving his life. It is prolonging the ultimate outcome, which is his death." 4. "The client understands his decision and the advanced stage of his disease. If he quits treatment, he will die."