A client is 12 hours post–kidney transplantation. The nurse notes that the client has put out 2000 mL of urine in 10 hours. Which assessment does the nurse carry out first?
a. Skin turgor
b. Blood pressure
c. Serum blood urea nitrogen (BUN) level
d. Weight of the client
B
After transplantation, the client may have diuresis. Excessive diuresis might cause hypotension. Hypotension needs to be prevented because it can reduce blood flow and oxygen to the new kid-ney, threatening graft survival. The other assessments can give information about fluid balance, but hypotension is the main concern here, so the nurse needs to check the client's blood pressure, then notify the provider.
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As the LPN/LVN discusses the care plan with the other staff, they note the following characteristics of a client's "at risk for" nursing diagnosis: Standard Text: Select all that apply
1. Problem statement 2. Factors contributing to the response 3. The words "related to" 4. Defining characteristics manifested by the client 5. Deviation from health
According to Lenburg, the use of practice-based assessments in nursing education is aimed toward the target of __________
Fill in the blank with the correct words.
The nurse determines a patient requires a fecal impaction removal. Which assessment result justifies the nurse's finding?
a. The patient exhibits rebound tenderness. b. The patient experiences hard stool that cannot be passed. c. The patient has a history of fecal impac-tion. d. The patient denies having a bowel move-ment today.
The paramedic should be MOST suspicious that a controlled substance has been tampered with if:
A) repeated doses of the same drug are administered and the patient experiences an adverse reaction. B) an appropriate dose of the drug seems ineffective, especially when patient tolerance is unlikely. C) the box that the drug is stored in is torn, even if the drug cartridge itself is structurally intact. D) there are any stray markings on the drug cartridge or vial, even if the contents are not discolored.