The nurse is collecting data from a patient with kidney disease. Which adventitious lung sound should the nurse recognize as being caused by fluid overload?
a. Stridor
b. Crackles
c. Wheezes
d. Pleural friction rub
ANS: B
Assessment of vital signs, lung sounds, edema, daily weights, and intake and output can provide valuable data related to urinary function. Fluid retention in the lungs is manifested as crackles, which are popping sounds heard on inspiration and sometimes on expiration. C. Wheezes might be heard however do not necessarily indicate fluid overload. A. D. Stridor and pleural friction rub are not heard in fluid overload.
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A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergies and no significant health history. Which action should the nurse include in this client's plan of care?
a. Initiate Airborne Precautions. b. Offer fluids every hour or two. c. Place an indwelling urinary catheter. d. Palpate the client's thyroid gland.
A nurse who works at an outpatient mental health clinic follows numerous clients who have schizophrenia, many of whom are being treated with olanzapine (Zyprexa)
Which of the following clients likely has the highest susceptibility to the adverse effects of olanzapine? A) A client who is morbidly obese and who has a sedentary lifestyle B) A client who has type 1 diabetes and who practices poor glycemic control C) A client who has a body mass index of 16.5 (underweight) and who smokes one pack of cigarettes daily D) A client who was recently treated with intravenous antibiotics because of cellulitis in his lower leg
The nurse has been asked to speak on diet and nutrition at a local town meeting. During the presentation, the nurse explains to the attendees about "Adequate Intake" and its primary purpose. What should the nurse say on this subject?
A) The primary purpose of the Adequate Intake is to provide the highest level of daily nutrient intake. B) The primary purpose of the Adequate Intake is to provide an estimate of the amount of nutrients required by individuals. C) The primary purpose of the Adequate Intake is to provide a value comparable with the RDA. D) The primary purpose of the Adequate Intake is to provide a goal for the nutrient intake of individuals.
Which patient statement made by a spouse is representative of those seen in Phase 3 of the crisis response regarding the death of a loved one?
a. "I don't know what I'll do to fill my days now." b. "Life isn't worth living if I have to live alone." c. "Prayer doesn't seem to give me the peace it has in the past." d. "Maybe going and spending time with my daughter will help."