A patient with a history of coronary artery disease is admitted with vomiting, abdominal distention, and hypoactive bowel sounds
Which of the following would provide the most accurate information about the patient's fluid volume status? 1. hourly urine output measurements
2. skin turgor assessment
3. pulmonary artery catheter
4. daily weights
3
Rationale: The patient has a history of coronary artery disease. The best way to determine fluid volume status and needs in this type of patient is with a Swan-Ganz catheter. Assessment of hourly urinary output is important, but not the best way to measure fluid volume status. Daily weight and assessing skin turgor are helpful but not as accurate as using a Swan-Ganz to assess the patient's fluid balance.
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The nurse has completed a community presentation about the changes of pregnancy. Which statement by a community member indicates that learning has occurred? "One probable or objective change of pregnancy is:
1. "Enlargement of the uterus." 2. "Hearing the baby's heart rate." 3. "Increased urinary frequency." 4. "Nausea and vomiting."
Initial and all subsequent data collected about the client become the foundation of the client database. This is termed baseline data
Indicate whether the statement is true or false
The nurse assesses the patient's intravenous (IV) insertion site and notes that it is warm, red, and tender. Which intervention should the nurse implement first?
a. Slow the infusion rate. b. Discontinue the IV infusion. c. Apply cool compresses. d. Apply warm compresses.
The male client is having difficulty using the urinal in bed. Which does the nurse implement to facilitate voiding into the urinal?
1. Applies an external urinary catheter 2. Assists client to the upright position 3. Encourages client to void every hour 4. Instructs client to increase fluid intake