The assessment by the nurse at the bedside of a patient with a chest tube attached to a water seal drainage that would require intervention is:
1. dependent loops in the chest tube.
2. the patient is in a semi-Fowler's position.
3. changing level of water in the water seal chamber.
4. level of drainage increase of 20 mL in 8 hours.
1
Dependent loops in the chest tube can collect drainage and occlude the system.
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A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness
A home health nurse is completing an admission on a patient who recently experienced a transient ischemic attack (TIA). During the assessment, the patient begins to complain of a severe headache and numbness in his left arm
Which action should the nurse take next? a. Instruct the patient to take Tylenol. b. Ask whether patient suffers from migraine headaches. c. Reschedule the visit. d. Call 9-1-1
A client has been admitted with a gastrointestinal ulcer. The client is NPO and has a nasogastric tube in place connected to low suction. What form of shock should the nurse monitor this client for?
A. Distributive shock B. Obstructive shock C. Cardiogenic shock D. Hypovolemic shock
A client is taking verapamil for hypertension, Glucotrol for management of type II diabetes, and melatonin for sleep. Which question should the nurse ask about these medications?
1. "How is the melatonin helping you with sleep?" 2. "How long have you been taking the verapamil for blood pressure control?" 3. "What was the result of your last hemoglobin A1C level?" 4. "What was your blood pressure before you began taking the verapamil?"