The nurse assesses the client with atherosclerotic disease. Which assessment is the nurse's priority?
1. +1 pedal pulse, pale toes
2. Carotid arteries without bruits
3. S1 and S2 heart sounds audible
4. 2-inch jugular venous distention
4
4. Jugular venous distention greater than 1 inch is a clinical indicator of fluid volume overload and is the nurse's priority because atherosclerosis is not a selective disease, meaning arteries throughout the body are potentially affected, and because the fluid overload is significant. Fluid volume overload for a client with atherosclerosis poten-tially indicates heart disease or heart failure.
1. Pedal pulses are easy to palpate at 2+ and skin should normally be pink; however, if the client is cold, vasoconstriction can induce these findings. The nurse ensures client warmth and comfort and reassesses the pulse and skin color.
2. Bruits indicate turbulent blood flow in an artery just like a murmur indicates it in the heart, so absence of carotid bruits is normal.
3. S1 and S2 heart sounds are normally audible.
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A patient is diagnosed with major depression with severe symptoms and begins taking an antidepressant medication. Three weeks after beginning therapy, the patient tells the nurse that the drug is not working
The nurse will counsel this patient to ask the provider about: a. adding a second medication to comple-ment this drug. b. changing the medication to one in a dif-ferent drug class. c. increasing the dose of this medication. d. using nondrug therapies to augment the medication.
Which of the following variables is a factor in drug absorption?
1. The smaller the surface area for absorption, the more rapidly the drug is absorbed. 2. A rich blood supply to the area of absorption leads to better absorption. 3. The less soluble the drug, the more easily it is absorbed. 4. Ionized drugs are easily absorbed across the cell membrane.
When incorporating the five rights of delegation, the right task is used in which situation?
a. The UAP reinforces use of the incentive spirometer to a patient. b. The UAP teaches the patient to use the incentive spirometer. c. The UAP listens to breath sounds to encourage the patient to use the incentive spirometer. d. The UAP is not allowed to work with the patient regarding use of the incentive spirometer.
Using evidence based practice interventions for a patient with acute kidney injury, the nurse is aware that the best approach for fluid volume excess management is:
1. A sodium-restricted diet 2. Diuretics 3. Fluid restriction 4. Plasmapheresis