A child with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. An important nursing intervention for this child would be to
1. reposition the child every two hours.
2. monitor B/P every 30 minutes.
3. encourage fluids.
4. limit visitors.
Answer:1
Rationale: A child with severe edema,on bed rest,is at risk for altered skin integrity. To prevent skin breakdown,the child should be repositioned every two hours. Vital signs are taken every four hours,fluids need to be monitored and should not be encouraged,and the child needs social interaction,so visitors should not be limited. Intervention
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A nurse notices that a patient has an irregular pulse. The nurse should do which of the following?
a. Count the number of "lub-dubs" occurring in 30 seconds. b. Assess how often the dysrhythmia is oc-curring. c. Assess the radial pulse for a pulse deficit. d. Chart the abnormally low heart rate as ta-chycardia.
The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical care unit, and is receiving a proton pump inhibitors (PPI) to reduce the risk for a stress ulcer
In this scenario, a stress ulcer is likely secondary to: a. infection with Helicobacter pylori bacteria. b. decreased acetylcholine production. c. a decreased number of parietal cells. d. ischemia associated with sepsis.
The nurse gives the example of when an individual becomes frightened and experiences increased heart rate and mental activity, along with increased blood flow to the skeletal muscles and dilated pupils, the person is experiencing an alarm reaction
that helps the body defend against stressors. This alarm reaction is the: 1. positive feedback response. 2. negative feedback response. 3. fight-or-flight response. 4. homeostasis response.
A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should be taken by the nurse?
1. Document the presence of decorticate posturing. 2. Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading. 3. Assess the position of the patient's arms. 4. Administer intravenous sedation as quickly as possible after access is obtained.