The handgrasps of the client with acidosis have diminished since the previous assessment 1 hour ago. What is the nurse's best first action?
A. Assess the client's rate, rhythm, and depth of respiration.
B. Measure the client's pulse and blood pressure.
C. Document the findings as the only action.
D. Notify the physician.
A
Progressive skeletal muscle weakness is associated with increasing severity of the acidosis. Muscle weakness can lead to severe respiratory insufficiency.
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A child in renal failure has hyperkalemia. The nurse plans to instruct the child and her parents to avoid which foods?
1. Carrots and green, leafy vegetables 2. Spaghetti and meat sauce with breadsticks 3. Hamburger on a bun and cherry gelatin 4. Chips, cold cuts, and canned foods
What should the nurse do when administering a therapeutic bath to a patient who has severe pruritus?
a. Use Burow's solution to help promote healing b. Rub the skin briskly to decrease pruritus c. Limit bathing to 3 times a week d. Ensure that bath area is at least 85 degrees and dehumidified
After a person was abducted and raped at gunpoint by an unknown assailant, which assessment finding best indicates the acute phase of the rape-trauma syndrome?
a. Decreased motor activity b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias
The nurse is assigned to care for a patient who is a non-native English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures?
a. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use. b. Contact the hospital's interpreter service for someone to translate. c. Get in touch with one of the residents that you know is fluent in the native language and ask him if he can come up to the unit. d. Use the 8-year old child who is fluent in both English and the native language to translate for you.