A patient's family voices concern regarding the purpose of some of the interventions for systemic inflammatory response syndrome (SIRS). What explanation by the nurse is most appropriate when explaining the rationale of treatment?
a. "Applying a MAST garment is mandatory to promote and conserve body heat."
b. "Inserting an IABP is required to decrease fluid leaking into the extravascular space."
c. "Maintaining strict isolation is vital to prevent an overlying bacterial infection."
d. "Aggressive treatment is necessary to support the multiple failing organs."
D
SIRS is the final and possibly fatal stage of shock. The body's defenses are supported aggres-sively and rapidly. MAST and IABP are measures used to increase circulating volume. Isolation is not indicated.
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The nurse caring for a client diagnosed with dehydration best assesses hydration by:
1. Checking tenting on both of the arms. 2. Checking tenting on the top of the hand. 3. Measuring the client's head circumference. 4. Checking skin tenting on the upper chest.
A nurse is caring for a client who is being prescribed phenazopyridine. The client is distressed on seeing that the urine is exhibiting a reddish-orange discoloration. Which response by the nurse would be most appropriate?
A) "We will have to get a specimen for a urinalysis." B) "I will have to notify the primary health care provider immediately." C) "You will need to increase your fluid intake." D) "This discoloration is a normal result of the medication. Nothing is wrong."
Sotalol rather than amiodarone was chosen as the first antidysrhythmic agent used for Mr Thomas. What reasons might have prompted this decision?
What will be an ideal response?
You may need several washcloths to perform the perineal care procedure without contamination.
Answer the following statement true (T) or false (F)