A patient with acute kidney injury is receiving treatment for fluid volume overload. Which of the following would indicate to the nurse that the treatment is successful?
1. normal serum protein level
2. soft formed stools
3. improved lung sounds
4. normal cardiac rhythm
3
Rationale: In fluid volume overload, the patient will demonstrate signs of pulmonary edema, peripheral edema, and increased weight. Evidence of successful treatment would be improved lung sounds, reduction in peripheral edema, and stabilization of weight towards normal. A normal serum protein level would be outcome criteria for the nursing diagnosis of altered nutrition. Soft formed stools would also be outcome criteria for the nursing diagnosis of altered nutrition. A normal cardiac rhythm would be outcome criteria for the nursing diagnoses related to electrolyte imbalances, metabolic acidosis, and cardiac dysfunction.
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Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.)
a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen
An older client in an adult day care program tells the nurse that, "I'm very stressed because another neighbor passed away." The most therapeutic response by the nurse is:
a. "What do you mean by 'stressed'?" b. "Tell me what you did when your other neighbor passed away." c. "Are you worrying about your own death?" d. "Let's get involved in some activities and not think about sad things."
What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client?
A. To clarify personal attitudes, values, and beliefs B. To obtain thorough assessment data C. To determine the client's length of stay D. To establish personal goals for the interaction
A physician has ordered the use of an inhaler for a patient with a respiratory condition, but the patient finds that taking deep breaths is very difficult. The nurse should
A) change the route of administration to liquid sprays. B) ask the patient to make a better effort to take deep breaths. C) use a spacer to facilitate easier inhalation of the drug. D) contact the prescriber for a recommendation.