The nurse is caring for a client with bilateral rales audible in the bases of the lung, jugular vein distention, and a low hematocrit. The nurse attributes these symptoms to which of the following?
1. Fluid volume deficit
2. Fluid volume balance
3. Fluid volume excess
4. Elevated serum calcium and magnesium levels
3
Rationale: These symptoms are classic manifestations of fluid volume overload or excess causing fluid to shift into the lungs and causing dilution of cells in the hematocrit.
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An ICU nurse does not follow policy when administering a medication intravenously. Which would be the most appropriate action by the manager to assist the employee?
1. Provide written instructions for administering the medication. 2. Remediate the situation with the ICU staff. 3. Provide a copy of the policy and discuss the rationale for the policy as it relates to client care. 4. Reprimand the ICU nurse for giving the medication.
The student nurse writes a paper, deletes the errors and unnecessary words, and revises sentences to make the paper read better. What is the next step in the process?
1. Proof 2. Polish 3. Submit 4. Delete
The home care of the high-risk infant may include:
a. cleaning the umbilical cord several times daily with alcohol. b. providing continued respiratory support and oxygen. c. feeding the infant on a strict schedule. d. keeping the infant in the supine or prone position.
During detoxification, an alcoholic client becomes hypoglycemic. Which of these actions should the nurse take FIRST?
a. Administer dextrose. b. Encourage the client to eat to minimize withdrawal symptoms. c. Give the client thiamine prior to dextrose administration. d. Administer oxygen before starting an IV.