An unexpected outcome that the nurse is alert for when caring for a client on peritoneal dialysis is a:
A. Positive fluid balance
B. Decrease in body weight
C. Decrease in abdominal girth
D. Fluid return that is clear and slightly yellow
A
A. Positive fluid balance indicates excess fluid retained.
B. Increased weight or no weight change indicates fluid has been retained in peritoneal cavity.
C. Increased abdominal girth indicates retained fluid.
D. Expected color of returned fluid is clear or slightly light yellow.
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The home health nurse, in the home to change a decubitus dressing, notices that the wound has a musky odor and is weepier than the last visit, 2 days ago. Prioritize these nursing in-terventions for this situation:
1. Contact the case manager. 2. Assess the patient's entire skin, vital signs, and be prepared to describe the wound findings. 3. Cleanse the decubitus area well and redress the wound. 4. Chart the appearance of the decubitus completely. 5. Assess the client's mobility.
Which function is not performed in the brain stem?
a. connection of the upper and lower levels of the CNS b. control of vital functions such as heart rate and breathing c. prevention of coma by maintaining wakefulness d. help controlling motor functions
A nurse is working in a community of factory workers and is planning an educational session for wellness, targeting the young adult group. In order to address one of the health problems of this group, the nurse plans to:
1. help the group become more aware of marketing efforts by tobacco companies. 2. tell this group that smoking is unacceptable. 3. make sure the group is aware of the increased risk of liver disease and cancer of the esophagus. 4. counsel the group regarding addiction.
A nurse is assisting a client with borderline personality disorder in how to manage transient psychotic episodes that involve auditory hallucinations. The teaching is planned for times when the client is free of these symptoms
Which of the following would the nurse instruct the client to do first? A) Use skills to tolerate painful feelings. B) Practice deep abdominal breathing. C) Identify early internal cues of distress. D) Refer to cards listing potential symptoms.