A critically ill younger client has an elevated serum sodium level. Which action should the nurse take after learning of this laboratory value?
a. Evaluate for edema
b. Assess for skin tenting
c. Check body temperature
d. Obtain a pulse oximeter measurement
b. Assess for skin tenting
Assessing a client for skin turgor or "tenting" can be used to screen for hydration status. Although this may not be useful in older adults due to subcutaneous tissue loss and changes in skin elasticity related to aging, it may be a good indicator in a younger client. Hypernatremia refers to elevated serum sodium levels and signals the loss of water from the extracellular fluid. The condition of hypernatremia does not impact the client's oxygenation status, temperature or result in edema.
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A toddler is admitted to the surgical unit for planned closure of the temporary colostomy. The nurse completes the admission assessment and reviews the medical orders. Which order should the nurse question?
1. Clear liquids today. NPO tomorrow 2. Type and cross-match for one unit of packed red blood cells. 3. Rectal temperatures every four hours 4. Start an intravenous line with D5NS at 20 ml per hour.
After the second week of orientation the new nurse witnesses the death of a child in the ED. Which role should this nurse's preceptor focus on at this time?
1. Orientation of the nurse to protocols associated with this death 2. Socialization of the nurse to the staff 3. Counseling the new nurse 4. Serving as a role model
An older adult tells the nurse that he keeps waking up during the night. Which of the following statements made by the client is related to a risk factor for disturbed sleep?
A) "I take my Zoloft as soon as I get up in the morning." B) "I walk for half an hour after I eat breakfast." C) "I limit my coffee intake to one cup of regular in the morning." D) "I think the arthritis in my hips is getting worse."
The nurse is assessing a client for circumduction. To complete this assessment, the nurse would:
a. ask the client to move her leg backward in a circle. b. turn the client's foot and leg inward, pointing the toes toward the other leg. c. move the client's head in order to touch her ear to the shoulder. d. raise the client's straight arm forward to a position above her head.