The nurse reviews laboratory results for a client with cirrhosis and finds the following: hematocrit, 72%; blood urea nitrogen (BUN), 42 mg/dL; and sodium, 166 mEq/L. Which action by the nurse is most appropriate?
a. Check the client's blood pressure and pulse.
b. Increase the client's oral fluid intake.
c. Call the health care provider.
d. Document the results in the chart.
A
These values are all elevated, which can occur in hypovolemia. The nurse should assess the client for signs of hypovolemia, including tachycardia and hypotension. The nurse should consult with the provider about the client's fluid status before increasing oral fluids but after obtaining vital signs. Documentation should occur after all assessments have been completed and must include actions taken.
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The physician's admitting orders indicate that the client is to be placed in a Fowler's position. Upon positioning this client, how much will the nurse elevate the head of the bed?
A) 45 to 60 degrees B) 15 to 20 degrees C) 30 degrees D) 90 degrees
A client who has been breastfeeding a newborn for the last 3 months is experiencing an inflammation of the breast. The nurse realizes this client is experiencing:
1. intraductal papilloma. 2. mastalgia. 3. mastitis. 4. mastodynia.
The nurse is analyzing a 6-second ECG rhythm strip with the following findings: P to QRS ratio is 1:1; four regular R waves were present; QRS width was 0.10 second; PR interval was 0.18 second. The nurse documents this rhythm as:
1. Atrioventricular (AV) block with 2:1 ratio 2. Sinus tachycardia noted with AV junctional rhythm 3. AV complete heart block noted 4. Sinus bradycardia
During the school-age years, a malocclusion can occur. Which of the following statements best describes a malocclusion?
a. The upper and lower teeth come together in a way that the permanent upper and lower teeth do not approximate. b. A permanent tooth cannot come through the gum due to a baby tooth still being in place. c. The teeth and jaws are aligned in such a manner as to prevent the lips from coming together. d. The tag of skin under the tongue is so tight that until it is cut the tongue cannot work properly in concert with the teeth.