To indirectly estimate the jugular venous pressure (JVP) of a patient positioned supine at a 45° angle, you would measure in centimeters the distance from the
a. sternal notch to the point of maximum venous engorgement.
b. sternal angle (angle of Louis) to the top of the distended neck vein.
c. tip of the manubrium to the point of maximum venous engorgement.
d. xiphoid process to the top of the distended neck vein.
B
To estimate the JVP of a patient, place the patient at a 30° to 45° angle. Next, measure the vertical distance in centimeters from the patient's sternal angle to the top of the distended neck vein. A JVP reading less than 4 cm is considered normal. An elevated JVP can be caused by an increased right ventricular pressure, increased blood volume, or an obstruction to the right ventricular flow.
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A patient is admitted to the emergency department (ED) in respiratory distress. The results of his first arterial blood gases were pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80
The nurse evaluates the patient's treatment plan by examining repeat arterial blood gases (ABGs). The results are pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L. The nurse concludes which of the following? a. Respiratory acidosis; the treatment plan is ineffective. b. Metabolic alkalosis; the treatment plan is effective. c. Partial compensation; the treatment plan is ineffective. d. Complete compensation; the treatment plan is effective.
On the way to the biohazard disposal closet to dispose of IV tubing and a bag used on an HIV-positive client, the LPN drops the IV tubing and bag on the floor, causing a spill
The team leader's most appropriate action would be to do which of the following? 1. Quickly pick up the dropped supplies and dispose of them in the biohazard bag in the biohazard room. Ask housekeeping to place a small barricade over the spill until it can be mopped up later. 2. Find the floor maintenance person to pick up and dispose of the used equipment and mop the floor, reminding them to be sure and wash his or her hands with soap and water. Chart that the IV was infused and discontinued appropriately. 3. Call and report to designated personnel to come and cordon off the area from staff and patients; have the spill cleaned with approved infection and chemother-apy spill control procedures. 4. Chart the spill in the patient's chart, inform the RN when convenient, and have housekeeping mop up the spill.
The nurse is planning discharge teaching for a client who has a splenectomy. Which statement does the nurse include in this client's teaching plan?
a. "Avoid crowds and people who are sick." b. "Do not eat raw fruits or vegetables." c. "Avoid environmental allergens." d. "Do not play contact sports."
The nurse assessing a client with depression could use which of the following to help with the assessment process?
1. Glasgow Coma Scale 2. Beck Depression Inventory 3. The client's family members, for answering the assessment questions 4. More time talking with the client