Your assessment findings are consistent with fluid overload. What five findings led you to
that conclusion?
What will be an ideal response?
• VS (blood pressure [BP], heart rate [HR], respiratory rate [RR]) are elevated.
• Two units of packed RBCs were transfused over 3 hours.
• He began to experience shortness of breath within 11?2 hours of the transfusion.
• Crackles were auscultated in the bases of both lung fields, indicating fluid accumulation.
• Pao
2 74 mm Hg on 8 L oxygen.
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The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?
a. Explain that it will not be painful. b. Suggest to him that he not worry about losing just a little bit of blood. c. Discuss with him how his body is always in the process of making blood. d. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.
A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. Which of the following is an appropriate technique for this procedure?
A) Use sterile gloves to handle the entire drape surface. B) Fold the lower edges of the drape over the sterile-gloved hands. C) Touch only the outer 2 inches of the drape when not wearing sterile gloves. D) When reaching over the drape do not allow clothing to touch the drape.
Which statement demonstrates an understanding of accountability as it relates to a RN's nursing practice?
A) "I'm accountable for the care I personally delivery." B) "The LPNs are accountable for the care that I delegate to them." C) "RNs are accountable for the care provided by the healthcare team they direct." D) "Accountability varies according to the complexity of the care being given the client."
Which general manifestations should the nurse monitor for when conducting a physical assessment for a pediatric client who is diagnosed with cancer? Select all that apply
1. Infection 2. Polycythemia 3. Petechiae 4. Pain 5. Cachexia