The nurse is providing care to a patient with Guillain-Barré syndrome. Which laboratory result should the nurse evaluate first?
a. Electrolytes
b. Blood urea nitrogen (BUN)
c. Arterial blood gases (ABGs)
d. Hemoglobin (Hgb) and hematocrit (Hct)
ANS: C
ABGs monitor respiratory status, which is essential in case the patient's respiratory muscles become affected. B. Blood urea nitrogen (BUN) monitors kidney function. D. Hgb and Hct monitor blood loss or anemia. A. Electrolytes monitor fluid and electrolyte balance.
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A client has the following laboratory values: Ca2+ 8.7 mg/dL; K+ 4.2 mEq/L; Na+ 142 mEq/L. Which intervention by the nurse is most appropriate?
a. Prepare to administer IV potassium chlo-ride. b. Ask the lab to redraw and rerun the tests. c. Document findings and continue to assess. d. Prepare to administer aluminum hydrox-ide.
A patient with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective Tissue Perfusion related to the effects of neurogenic shock
The nurse includes which intervention in the patient's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fit the patient for an abdominal binder and thigh-length compression stockings. 2. Monitor administration of atropine and other vasoactive agents as ordered or by protocol. 3. Administer anticoagulant medication as ordered. 4. Measure and record the diameter of the calf every shift. 5. Measure and record intake and output.
A client who was recently admitted to the mental health unit has a history of paranoia. When the meal tray is delivered, the client refuses to eat and tells the nurse that someone is poisoning the food. Which statement by the nurse is appropriate?
A. "Your food is not poisoned." B. "Why do you think the food is poisoned?" C. "There is no poison in the food. Here, I'll taste the food for you." D. "It must be frightening to you. Has something made you feel that your food is poisoned?"
A home health nurse has been called to the home of an older postoperative cardiovascular client by the client's son. The son tells the nurse, "We're using a hospital bed here at home, but my mother has fallen out of bed three times." Which observation by the nurse reflects an increased risk of this client's falling out of bed?
A. The client's bed is in a low position. B. The client is oriented to person, place, and time. C. The caregiver uses the overbed table for feedings. D. The caregiver leaves both siderails down while the client is in bed.