The nurse is caring for a patient who is receiving fluid replacement after being burned on 37% of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg, heart rate of 120 beats/min, and urine output of 10 mL over the past hour
After reporting these findings, which order should the nurse expect to be prescribed for this patient?
a. Discontinue the IV fluid infusion.
b. Change the IV fluid to dextrose and water.
c. Increase the amount of IV fluid administered per hour.
d. Decrease the amount of IV fluid administered per hour.
ANS: C
In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic shock. Low blood pressure, elevated pulse, and low urine output indicate hypovolemia, so the nurse should anticipate increasing IV fluids. A. D. Decreasing or discontinuing fluids is inappropriate. B. Dextrose and water is hypotonic and will not maintain circulating volume.
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The treatment plan for a client with acute mania has been effective when the nurse charts that the client has:
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A patient has a serum sodium level of 119 mEq/L, a blood glucose level of 52 mg/dL, and a cortisol level of 1.1 mg/dL. What does the nurse add to this patient's plan of care?
A. Demonstrate proper technique to check blood glucose. B. Encourage the child to take salt tablets with each meal. C. Teach parents and child about desmopressin acetate (DDVAP). D. Teach parents and child about solumedrol (Solu-Cortef).
The nurse is teaching new nursing assistants on the unit about the phenomenon of muscle hypertrophy. Which of the following clients on the unit is most likely to experience muscle hypertrophy? A client with
A) urinary incontinence following a cerebral vascular accident (CVA). B) hypertension, obesity, and decreased activity tolerance. C) peripheral edema secondary to heart failure (HF). D) possible rejection symptoms following a liver transplant.
The nurse is caring for a group of four clients who are seriously ill. One of the clients has just received a new cardiac medication
How should the nurse instruct the unlicensed assistive personnel (UAP) who is also caring for this client? A) Have the UAP look the medication up in a drug reference book to read about drug actions and possible side effects. B) Have the UAP assess for any unexpected effects from the medication. C) Tell the UAP to teach the client's family what to expect from the medication. D) Give the UAP specific instructions regarding what drug actions or side effects to report to the nurse.