The nurse contributes to the plan of care for a patient who has a nursing diagnosis of Deficient Fluid Volume related to anorexia, nausea, vomiting, and excessive T-tube drainage related to cholecystitis

Which interventions should the nurse recommend be included in the plan of care? (Select all that apply.)
a. Monitor daily weight and intake and output.
b. Administer antiemetics as ordered.
c. Contact the physician if T-tube drainage is greater than 150 mL within 24 hours of surgery.
d. Clamp T-tube for 2 hours each shift.
e. Monitor skin turgor.
f. Encourage use of incentive spirometer every hour while awake.


ANS: A, B, E
Daily weights, intake and output, and skin turgor are good measures of fluid balance. Antiemetics will help reduce vomiting and contribute to fluid balance. About 250 to 500 mL of yellowish-green bile is common within the first 24 hours after surgery. Clamping the T-tube is inappropriate and may put pressure on the surgical site.

Nursing

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The nurse suspects that an older client has no living family members and observes the client sitting quietly in the room, crying. What actions should the nurse take to intentionally know this client?

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Nursing

A client receives cefazolin sodium (Ancef) by way of the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. The nurse most accurately documents which of the following?

A. The client had an allergy to cefazolin sodium. B. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium. C. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back. D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.

Nursing