The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?
A) Endotoxins in the system
B) Limited gas exchange
C) Brain death
D) Multiple organ failure
D
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In the irreversible stage of shock, significant cells and organs are damaged. The client's condition reaches a "point of no return" despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.
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An elderly man who has come to a health promotion clinic offering education related to understanding and filling out advance directives tells the nurse
that he does not want to complete an advance directive because he does not want anyone controlling his finances. The nurse teaches the man that: A) Advance directives are not legal documents, so he has nothing to worry about. B) Advance directives are limited only to health care instructions and directives. C) His finances cannot be managed without an advance directive. D) Advance directives are implemented when you become incapacitated, then you use a living will to allow the state to manage your money.
The nursing staff on a labor and delivery unit analyze current research results regarding the use of the birthing ball for pain control during labor before they initiate this intervention on their unit. This is an example of
a. evidence-based practice c. benchmarking b. critical-thinking processes d. best practice
The client is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses cyanosis, slow respirations, and irregular pulse. What is the nurse's priority action?
1. Continue the infusion; the client is still in acidosis. 2. Increase the rate of the infusion and continue to assess the client for symptoms of acidosis. 3. Stop the infusion and notify the physician; the client is in alkalosis. 4. Decrease the rate of the infusion and continue to assess the client for symptoms of alkalosis.
After turning the patient, the very last step in any turning procedure is to
A) wash your hands. B) straighten out the covers. C) wait ten minutes to see if the patient is comfortable. D) report to your immediate supervisor that you have changed the patient's position.