The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action?
A. Raise the head of the bed.
B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.
B
Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway and the swelling usually precludes intubation.
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Which of the following statements are correct regarding epithelial cells of the gastric mucosa? (Select all that apply.)
a. They prevent diffusion of hydrogen into the mucosa. b. They secrete bicarbonate to neutralize hydrogen ions. c. They have the ability to increase blood flow to facilitate removal of toxic metabolites. d. They break down prostaglandins.
When assessing a client for the risk of pressure ulcer development, what factors must be a part of the assessment? Select all that apply
1. Sensory perception and activity level 2. Moisture 3. Mobility 4. Nutrition 5. Friction and shear
Tom is an 18-year-old high school student who came to the clinic with complaints of frequent urination. He has been feeling more tired than usual. He reports losing 13 pounds unintentionally in the past three months, and is more hungry than usual
Lab results showed no bacteria or white blood cells in the urine, but ketones were present. The CBC was normal with no elevation in white blood cells. A metabolic profile was normal except for glucose which was 132. At his follow-up visit the nurse should ask about: 1. Recent weight gain, sexual activity, and frequent thirst. 2. A family history of diabetes, recent weight gain, and blurred vision. 3. Recent weight loss, frequent thirst, and increased hunger. 4. A family history of diabetes, lack of thirst, and recent weight loss.
As part of routine data collection, a nurse is required to observe the characteristics of
urine of his clients. Which statement is true regarding the characteristics of urine? A) Light amber-colored urine is seen in the case of dehydration B) Strong ammonia-like odor is normal in freshly voided urine C) Change in the normal color of urine may be caused by medications D) Orange-brown colored urine is seen in the case of overhydration