The client experiences cramping during instillation of the peritoneal dialysis. The nurse should:
A. Check the temperature of the solution
B. Have the client move around in bed
C. Increase the flow rate of the solution
D. Remove all of the solution from the client quickly
A
A. Dialysate that is too cold results in intolerance, cramps, and hypothermia.
B. Place client in semi-Fowler's or high-Fowler's position. This position promotes optimal lung expansion.
C. Infuse the solution over prescribed time, usually 2 L/10-15 min.
D. Unclamp outflow tubing and drain, usually for 20 minutes.
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When you assess the client with a new tracheotomy at the beginning of your shift, you observe that the tracheostomy tube is pulsating in synchrony with the client's heartbeat. What is your best action?
A. Notify the physician immediately. B. Stabilize the tube by reapplying the ties. C. Document the observation as the only action. D. Increase the inflation pressure of the tracheostomy cuff.
The client asks the nurse how his ranitidine works to treat his heartburn. The nurse's best response is:
a. "Ranitidine block the histamine-2 receptors in the stomach to decrease gastric acid." b. "Your medication works by blocking histamine release to decrease gastric acid." c. "Ranitidine is a proton pump inhibitor that causes a decrease in the release of gastric acid." d. "Your medication works by suppressing pepsin, an enzyme in the stomach."
Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter?
a. "How much milk do you drink?" b. "What medications are you taking?" c. "Are your immunizations up to date?" d. "Have you had any recent neck injuries?"
A mother and her 4-week-old infant have arrived for a health maintenance visit. Which activity will the nurse perform?
A) Assess the child for an upper respiratory infection B) Take a health history for a minor injury C) Administer a varicella injection D) Plot the child's head circumference on a growth chart