During data collection, the nurse learns that a patient with chronic cardiac problems and diabetes has gained 5 pounds of weight over 3 days and is experiencing fatigue when climbing stairs
Upon inspection, the nurse notes edema of the lower extremities. What health problem do these symptoms suggest that the nurse should report to the physician?
a. Acute heart failure
b. Myocardial infarction
c. Left-sided heart failure
d. Right-sided heart failure
ANS: D
These are signs of right-sided heart failure because fluid is being retained (weight gain), backing up systemically. The patient is fatigued due to reduced cardiac output and oxygenation. The nurse should report these symptoms right away. A. B. C. These symptoms are not consistent with acute heart failure, myocardial infarction, or left-sided heart failure.
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At a recent staff meeting the staff educator discussed the importance of catheter care for the prevention of urinary tract infections (UTI). What percentage of health care–associated infections result from indwelling catheter use?
a. 10% b. 60% c. 70% d. 80%
A client with major burn over 20% of the body has abdominal distention. The nurse suspects the client might have a paralytic ileus due to:
1. a lack of intestinal motility. 2. infection. 3. decreased food intake. 4. capillary leaks.
An infant who weighs 9 pounds and has an order for Kantrex (kanamycin sulfate) 30 mg IV every 12 hours. The literature states the recommended dosage is 15/kg/day in two divided doses. The vial is labeled 75 mg/2 mL
How many milliliters should the nurse administer per dose? A) 0.8 B) 0.9 C) 1 D) 1.1
Which are discharge criteria the nurse includes in the plan of care for a client who has received sedation? Select all that apply
1. Stable vital signs 2. Patent airway 3. Ability to sit up without assistance 4. Adequate fluid intake 5. Ability to urinate