Posted: August 10th, 2021
A nurse is caring for a consumer with a spinal twine injury. What are attainable causes of autonomic dysreflexia that the nurse ought to watch for? distended bladder (most common), fecal impaction, chilly stress or drafts on lower part of physique, tight garments, undiagnosed injury or illness. A nurse is caring for a consumer who has merely undergone a craniotomy for a supratentorial tumor. Which of the following postoperative prescriptions should the nurse clarify with the provider?
A. Dexamethasone (Decadron) 30 mg IV bolus BID
B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for ache
C. Ondansetron (Zofran) 4 mg IV bolus PRN every 4 to 6 hr for nausea D. Phenytoin (Dilantin) 100 mg IV bolus TID
A client has been admitted to the hospital with a prognosis of tuberculosis. Current three (three) measures the nurse can take to cease sickness transmission. Use N-95 respirator, place shopper unfavorable airflow room (airborne precautions), use barrier security when the possibility of hand or garments contamination occurs.
A nurse is caring for a consumer who has been admitted with renal calculi. Report three (three) interventions the nurse will take throughout the administration of renal calculi. Encourage elevated oral consumption to 3L/day besides contraindicated, encourage ambulation to promote passage of stone, Strain all urine to check for passafe of the stone and save the stone for lab analysis.
Define the following types of urinary incontinence: Stress, urge, overflow, reflex, purposeful, entire. Stress – lack of small portions of urine with sneezing, laughing, or lifting. Stress incontinence is expounded primarily to weak pelvic muscular tissues, urethra, or surrounding tissues.
Urge – the shortcoming to stop urine stream prolonged ample to realize the toilet. Urge incontinence is expounded to an overactive detrusor muscle with elevated bladder pressure. Overflow – urinary retention associated to bladder overdistention and frequent lack of small portions of urine.
Overflow incontinence is expounded to obstruction of the urinary outlet or an impaired detrusor muscle. Reflex – involuntary lack of a common amount of urine usually with warning. Reflex incontinence is expounded to hyperreflexia of the detrusor muscle, usually from altered spinal twine train. Helpful – incapability to get to the toilet to urinate. Helpful incontinence is expounded to bodily, cognitive, or social impairment. Complete incontinence – involuntary, unpredictable lack of urine that does not normally reply to treatment.
A nurse is providing education to a consumer with hypertension regarding the significance of sustaining antihypertensive treatment. What are three (three) points that will occur with prolonged, untreated or poorly managed hypertension? peripheral vascular sickness that impacts the middle, thoughts, eyes, and kidneys. Hypertrophy of the left ventricle can develop as the middle pumps in opposition to resistance introduced on by HTN.
A nurse is caring for a consumer experiencing metabolic acidosis. What are three (three) causes of metabolic acidosis? additional manufacturing of hydrogen ions (DKA, lactic acidosis, starvation, heavy practice, seizure train, fever, hypoxia, intoxication with ethanol or salicylates), inadequate manufacturing of bicarbonate (kidney failure, pancreatitis, liver failure, dehydration), additional elimination of bicarbonate (diarrhea, ileostomy)
A nurse is caring for a consumer with pneumonia. What are three (three) bodily analysis findings which could be well-known with the occasion of pneumonia? uninteresting chest percussion over areas of consolidation, decreased o2 sat, purulent blood tinged/rust colored sputum (not on a regular basis), fever, chills, flushed face, diaphoresis, SOB, tachypnea, pleuritic chest ache (sharp), yellow tinged sputum, crackles and wheezes
A nurse is caring for a consumer scheduled for a liver biopsy. What nursing actions must be taken sooner than, all through and after this course of? Sooner than course of make clear course of, witness educated constent, assure shopper fasts for on the very least 2 hr., administer preprocedural meds as prescribed. All through course of assist the patron into supine with URQ of abd uncovered, assist shopper with relaxation methods, instruct shopper to exhale breath and preserve for on the very least 10 seconds whereas the needle is inserted and to resume respiration as quickly because the needle is withdrawn, apply pressure to puncture web site. After course of assist shopper to a correct side-lying place and protect for a variety of hours, monitor essential indicators, assess for ache and bleeding
A nurse is caring for a consumer with colorectal most cancers who's scheduled for a colectomy. What preoperative and post-operative education must be provided to this shopper? educate shopper regarding preop weight reduction plan (clear liquids a variety of days earlier to surgical process), instruct the cliet to complete bowel prep with cathartics as prescribed, inform the patron of the administration of antibiotics to eradicate intestinal flora. postop educate the patron regarding the care of the incision, train limits, and ostomy care if related.
A worker is taken the employee nicely being nurse with an obvious open fracture to the suitable arm. What priority care measures should the nurse current whereas awaiting emergency transport ABCs, stabilize injured house along with joints above and beneath fracture, stay away from pointless movement
A nurse is caring for a consumer with a variety of hazard parts for peripheral vascular sickness. Report four (4) hazard parts associated to peripheral vascular sickness. Hypertension, hyperlipidemia, diabetes mellitus, cigarette smoking, weight issues, sedentary lifestyle, familial predisposition
A client is recognized with Addisonian Catastrophe. Report the lab values that can possible be affected by this sickness course of. elevated potassium, decreased sodium, and elevated calcium, BUN and creatinine elevated, serum glucose decreased, serum cortisol decreased
A nurse is caring for a consumer with a stress pneumothorax. What's a stress pneumothorax and what manifestations should the nurse anticipate? a stress pneumothorax occurs when air enters the pleural home all through inspiration by means of a one-way valve and is not able to exit upon expiration. the trapped air causes pressure on the hear and lung. Due to this the rise in pressure compresses the blood vessels and limits venous returen, leading to a decrease in cardiac output. Demise might outcome if not dealt with immediately. manifestations- tracheal deviation to unaffected facet, respiratory distress, uneven chest wall movement.
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