The nurse is monitoring a client with liver failure. Which assessments does the nurse perform when monitoring for bleeding in this client? (Select all that apply.)
a. Gums
b. Lung sounds
c. Urine
d. Stool
e. Hair
A, C, D
The liver is the site for production of clotting factors. Without these factors, the client is at risk for bleeding. Common areas of bleeding include the gums and mucous membranes, bladder, and gastrointestinal tract. Lung sounds and hair are part of the assessment but are not essential in the presence of liver failure and hematologic abnormalities.
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During the immediate postpartum period, the mother has a temperature of 100.2° F, pulse 52, respirations 18, BP 138/84 . What should the nurse do?
a. Report the temperature as abnormal. b. Continue to monitor every 15 minutes. c. Report the pulse as abnormal. d. Report that vital signs are normal.
A nursing student asks a nurse why patients with chronic renal failure (CRF) have low erythro-cyte counts. Which response by the nurse is correct?
a. "Damage to the renal tubules increases serum blood loss." b. "Dialysis accelerates the breakdown of red blood cells." c. "Erythropoietin is no longer produced by cells in the kidneys." d. "Patients with CRF are deficient in iron, folic acid, and vitamin B12."
The daughter of a patient who has been diagnosed with terminal cancer asks which documents are required to allow her to make health care decisions for her parent. Which response would provide the most information to the daughter?
a. Advance directives indicate the degree of intervention desired by the patient. b. A ‘Do Not Resuscitate' document signed by the patient transfers authority to the next of kin. c. A durable power of attorney for health care transfers decision-making authority for health care to a designated person. d. A living will transfers authority to the physician.
All of the following types of nerve impulses are carried by the axons of afferent neurons except:
A. nerve impulse for temperature. B. nerve impulse for directing organ activity. C. nerve impulse for pain. D. nerve impulse for touch.