The nurse is caring for a client who is 2 days postop and whose vital signs show the following: pulse of 112, blood pressure of 96/52, and a urine output of 15 cc/hour
Which of the following postoperative problems could present with those signs? Standard Text: Select all that apply. 1. UTI
2. Embolus
3. Hypovolemia
4. Hemorrhage
5. Hypovolemic shock
3,4,5
Rationale: A urinary tract infection presents clinically as cloudy and/or foul-smelling urine, with the client complaining of burning with voiding, or lower abdominal pain.
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The nurse is concerned that an older patient is experiencing dehydration. What did the nurse assess in this patient? Standard Text: Select all that apply
1. Confusion 2. Headache 3. Weight gain 4. Long tongue furrows 5. Forearm tenting of the skin
A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?
A) The spleen is a large lymph node and takes waste debris away. B) The spleen is a lymphatic structure and assists with phagocytosis. C) The spleen is lymphoid tissue in the upper chest that contains stem cells. D) The spleen assists with blood clotting.
A nurse is discussing internal family coping strategies with a family following a family crisis. Which of the following would the nurse be explaining?
a. Asking a distant relative for a loan b. Talking to relatives about stresses and worries c. Attending a local worship service d. Using public assistance to obtain food stamps
The nurse is explaining to a patient the procedure to alleviate pressure on a casted extremity. How should the nurse explain the procedure?
A. "This procedure is called an external fixation and will help the bone heal." B. "This procedure will help heal your leg faster so that the cast can come off sooner." C. "This procedure is called an open reduction with internal fixation to help the bone fuse together." D. "This procedure is called bivalving. The doctor will use a cast saw to split the cast down both sides to relieve pressure on your leg."