While assessing edema on a client's lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the client's leg. The nurse records this finding as:
a. No edema.
b. 1+ edema.
c. 2+ edema.
d. 3+ edema.
ANS: B
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A nurse working in the ICU receives orders for dopamine, which is an intravenous vasoactive drug. The priority assessment and interventions specific to the administration of vasoactive medications are:
A) Frequent vitals, monitoring the central-line site, and providing accurate drug titration B) Reviewing medications, performing a focused cardiovascular assessment, and providing patient education C) Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema. D) Routine vitals, monitoring the peripheral IV site, and providing early discharge instructions.
The nurse is caring for a client who is being treated for anemia and is taking Imferon IM. The nurse should plan to administer this medication:
1. IV. 2. PO. 3. Subcutaneously. 4. Via the z-track method.
The nurse is caring for a client who has SIADH. The nurse notices that the client has become confused and extremely short of breath, and crackles are heard when lungs are auscultated. What is the first action by the nurse?
A) Administer a diuretic. B) Notify the physician. C) Lay the client flat. D) Suction the client.
When differentiating between bereavement symptoms and depression, the nurse will base the formulation on knowledge that in bereavement:
a. Suicide thoughts are common. b. Symptoms remit and exacerbate. c. Guilt feelings are overwhelming. d. Psychomotor retardation is obvious.