The nurse is monitoring a patient with chronic kidney disease. Which findings should the nurse realize indicates fluid overload? (Select all that apply.)
a. Periorbital edema
b. Crackles in the lungs
c. Postural hypotension
d. Increased blood pressure
e. Decreased pulse pressure
f. Auditory wheezes on inspiration
ANS: A, B, D
Neck vein distention, periorbital edema, hypertension and crackles in the lungs are symptoms of fluid overload. C. E. F. Postural hypotension, decreased pulse pressure, and auditory wheezes on inspiration are not manifestations of fluid overload.
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When assessing the client newly diagnosed with Addison's disease, before treatment has begun, the nurse would find what skin color most consistent with the diagnosis?
1. Pale 2. Cyanotic 3. Jaundiced 4. Bronze
The physician prescribes glyburide (Micronase, DiaBeta, Glynase) for a patient, age 57, when diet and exercise have not been able to control type 2 diabetes
What should the nurse include in the teaching plan about this medication? a. It is a substitute for insulin and acts by directly stimulating glucose uptake into the cell. b. It does not cause the hypoglycemic reactions that may occur with insulin use. c. It is thought to stimulate insulin production and increase sensitivity to insulin at receptor sites. d. It lowers blood sugar by inhibiting glucagon release from the liver, preventing gluconeogenesis.
A client in an inpatient mental health setting is scheduled to be discharged, with follow-up at a community mental health center. His family is concerned that his inpatient stay was not long enough, and he will be re-admitted in the near future
The nurse knows that the average length of inpatient stay is: a. 5 days b. 10 days c. 25 days d. 1 month
Which of the following is not a cause of pressure injuries?
A. Loss of circulation B. Cleanliness C. Friction D. Shearing