The nurse assesses the client who has bilateral pressure ulcers on the heels and is on an air-suspension mattress. Which does the nurse determine is an unexpected outcome of therapy for this client?
1. Client has a stage I pressure ulcer at left trochanter.
2. Client has bibasilar crackles after 3 days of therapy.
3. Client has nausea 1 day after beginning the treatment.
4. Client has dry mucous membranes and hypernatremia.
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3. A client on an air-suspension mattress can complain of nausea because of the con-tinual floating sensation. Many clients adjust to the sensation; however, the nurse provides antihistamines or antiemetics to reduce the sensation and allow continuation with the pressure-reducing support surface.
1. The nurse uses a support surface to promote skin integrity and healing by redistri-buting pressure over a larger client surface or reducing the pressure; thus, an unex-pected outcome for any support surface is a new area of skin breakdown. Neverthe-less, a new area of skin breakdown is a nonspecific unexpected outcome for support surfaces.
2. Crackles are an unexpected outcome of a Rotokinetic bed.
4. Dehydration and dry skin are unexpected outcomes of air-fluidized beds because the beds reduce pressure by suspending ceramic beads under a polyester sheet with temperature-controlled air. The continuous air currents passing over the client's skin dehydrate the client by accelerated evaporation.
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A group of 100 students took a test. The mean was 85, the standard deviation was 5, and the scores were normally distributed. About how many of the 100 scores fell between 80 and 90?
A) 34 B) 68 C) 95 D) Impossible to determine
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding?
A) "Can't walk without becoming short of breath." B) "Has paroxysmal nocturnal dyspnea when walking." C) "Has orthopnea when walking." D) Experiences exertional dyspnea when walking 3 feet; states, "I cannot catch my breath."
A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration
Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document? A) The client has a funnel chest. B) The client has chronic respiratory disease. C) The client has pneumonia in the bases. D) The client needs a cough suppressant.
While caring for a patient with a pulmonary arterial catheter, the nurse notes that the number of centimeters of the catheter has decreased. Which of the following should be done at this time?
1. Report this finding immediately; the patient may need another chest x-ray to check for placement. 2. Flush the ports. 3. Zero balance the system. 4. Obtain a pulmonary artery occlusion pressure.