Which of the following clients should be assessed for hypovolemic shock?
a. A 77-year-old with cellulitis of the leg who received vancomycin
b. A 60-year-old with a lupus flare up receiving normal saline at 125 mL/hr
c. A 25-year-old who came in for vomiting with the last emesis 12 hours ago
d. A 45-year-old with +2 pitting edema receiving furosemide
d. A 45-year-old with +2 pitting edema receiving furosemide
rationale: The client receiving furosemide is at risk for depleting too much fluid and is also experiencing third spacing, indicated by the 2+ edema. This can lead to hypovolemia. Causes of hypovolemic shock include body fluid depletion, hemorrhage, and dehydration from severe vomiting, diarrhea, hyperglycemia, and diuretic therapy.
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Which indicate factors affecting communication clarity? Select all that apply
1. A nursing supervisor talking with a staff nurse 2. Two female staff nurses talking after work 3. A 63-year-old nurse discussing work with a 25-year-old 4. A staff nurse discussing changing policies with the manager 5. An Asian student attending nursing school in the United States
The timely flow of information is critical to institutional survival. Which of the following statements about interfaces is accurate?
1. Interfaces use an open systems technology provided by the vendor. 2. Interfaces require installation of a Health Level Seven (HL7) device. 3. Interface connections between different information systems are invisible to the user. 4. Interfaces physically join two or more disparate information systems.
The nurse observes the arm of a patient who was given the Mantoux skin test for tuberculosis. There is induration of 3 mm. The nurse documents that the results are:
1. negative. 2. questionable. 3. positive for exposure. 4. positive for TB.
A client in the manic phase of bipolar disorder is unable to sleep during the night. Which of the following interventions could be helpful to this client?
1. Encourage to watch television 2. Assist with a warm bath and provide a light snack 3. Engage in conversation 4. Extend daytime naps