The nurse is caring for a client whose I&O is being monitored. Immeasurable fluid losses include: Standard Text: Select all that apply
1. Extreme diaphoresis.
2. Rapid, deep respirations.
3. Urine.
4. NG drainage.
5. IV fluid.
1,2
Rationale: Extremely diaphoretic clients can lose significant amounts of fluids that contribute to fluid imbalance.
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Documentation in a client's chart includes the following information: "Throughout a 5-minute interaction the client fidgeted and tapped his left foot, periodically covered his face with his hands, looked under his chair, all while stating he was enjoying spending time with this nurse.". Of the following assessments, which is most accurate?
a. The client is giving positive feedback about the nurse's communication techniques. b. The nurse is viewing the client's behavior through a cultural filter. c. The client's verbal and nonverbal messages are incongruent. d. The client is demonstrating psychotic behaviors.
You are preparing your patient for surgery. Prior to obtaining your patient's signature on the operative permit, you ask the patient if she understands all aspects of the surgical procedure
The patient replies that she is very nervous and really does not understand what the surgical procedure is or how it will be performed. What is the most appropriate nursing action for you to take? A) Have the patient sign the operative permit and place it in the chart B) Call the physician to review the procedure with the patient C) Explain the procedure to the patient and her family D) Provide the patient with a pamphlet explaining the procedure
A gentleman that is being assessed for high blood pressure tells the nurse that he is worried about his teenage son who has started using drugs and alcohol and does not listen to him
What should the nurse suggest to the client to help his son overcome peer pressure? 1 . Model safe habits and practices. 2 . Promote a safe home environment where the son receives appropriate responses. 3 . Give information about the hazards of risk taking. 4 . Acknowledge inappropriate practices that the son participates. A) 1, 2, 3 B) 1, 2, 4 C) 1, 3, 4 D) 2, 3, 4
The primary reason a client with chronic obstructive pulmonary disease (COPD) often experienc-es fatigue and activity intolerance is related to:
1. The increased presence of surfactant that results in "sticky" alveoli 2. The presence of chronic infections in the lungs and bronchial tree 3. The extra energy that is needed to exhale the air from the damaged lungs 4. The client's elevated anxiety level related to the air hunger being experienced