A client who is admitted to the hospital with a history of kidney disease begins to have difficulty breathing. Vital signs are as follows: blood pressure, 90/70 mm Hg; heart rate, difficult to feel peripheral pulses
His heart sounds are difficult to hear. Which intervention does the nurse pre-pare for? a. Administration of digoxin (Lanoxin)
b. Draining of pericardial fluid with a needle
c. Emergency hemodialysis
d. Placement of a pacemaker
B
These signs and symptoms are of cardiac tamponade, an emergency situation in which fluid ac-cumulates in the pericardial sac, making it difficult for the heart to pump normally. Treatment includes a pericardiocentesis, or withdrawing the fluid with a needle or catheter. The other inter-ventions are not appropriate in this situation.
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While bathing the client, the nurse observes large purple-colored rashes on the client's chest. How should the nurse document this finding?
1. Papules 2. Erythema 3. Purpura 4. Petechiae
The nurse is teaching the family of a child with type 1 diabetes about insulin. What should the nurse include in the teaching session? (Select all that apply.)
a. Unopened vials are good for 60 days. b. Diabetic supplies should not be left in a hot environment. c. Insulin can be placed in the freezer if not used every day. d. After it has been opened, insulin is good for up to 28 to 30 days. e. Insulin bottles that have been opened should be stored at room temperature or refrigerated.
For the absorption of heavy exudate from a wound, a nurse selects a dressing that contains:
A. Alginates B. Hydrogel C. Hydrocolloid D. Transparent film
MC Equipment removed from an AIDS client's room should be cleaned with
A. Phenolic disinfectant. B. Benzalkonium chloride. C. Iodophore. D. Germicidal soap and water.