List five additional interventions that need to be performed for C.J. and the rationale for the
use of each.
What will be an ideal response?
• Antibiotics: The patient should receive prophylactic broad-spectrum antibiotics after all culture
samples have been obtained.
• Blood glucose checks: These should be performed every hour until glucose stabilizes within
normal limits (WNL).
• Serum potassium levels: Insulin drives potassium into the cell; therefore the nurse should monitor
serum potassium levels every 1 to 2 hours to prevent complications such as dysrhythmias, altered
level of consciousness, and seizure activity.
• Continuous cardiac monitoring: This should be done to monitor for dysrhythmias associated with
hypokalemia.
• Strict intake and output with placement of a urinary catheter: This will assist in ensuring accurate
assessment of fluid volume status.
• Potassium should be added to the IV solution to replace potassium ions in the extracellular fluid
that will be pushed back into the cells.
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The nurse clarifies that the condition that would necessitate an ostomy would be:
1. tumor obstructing the digestive tract lumen. 2. congenital absence of one ureter. 3. chronic diarrhea. 4. fracture of the pelvis and pubis.
If pitting edema is unilateral, you would suspect occlusion of a:
a. lymphatic duct. b. major vein. c. surface capillary. d. superficial artery.
Which pre-existing client problem or characteristic would preclude the use of radiation therapy for breast cancer treatment?
A. The client is a Jehovah's Witness. B. The client is over 75 years of age. C. The client underwent a lumpectomy for the breast cancer one month ago. D. The client has severe arthritis and cannot assume the position needed for radiation therapy.
A senator develops a sexual relationship with a 20-year-old receptionist. Which adjective most likely applies to this relationship?
a. Harmonious b. Consensual c. Coercive d. Illegal