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Document The Finding Fluid Volume Excess Nursing
Cirrhosis case study – Flashcards 24 terms
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Jamie Hutchinson
24 terms
Community Health Document The Finding Health Assessment Lower The Temperature Nursing
Hesi CS: Healthy Newborn – Flashcards 23 terms
Elizabeth Bates avatar
Elizabeth Bates
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Advise The Client Document The Finding Fluid Volume Excess Nursing
HESI Case Study- Cirrhosis – Flashcards 24 terms
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Roman Peck
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Document The Finding Health Science Nursing
HESI Case Study-Healthy Newborn – Flashcards 23 terms
Sean Hill avatar
Sean Hill
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Document The Finding Foundations Of Professional Nursing Health Assessment Nursing
HESI abdominal assessment case study – Flashcards 25 terms
Ewan Knight avatar
Ewan Knight
25 terms
6. Twenty minutes after the client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. What is the nurse’s best first action? A. Document the findings as the only action. B. Check the client’s pulse and blood pressure. C. Prepare to administer epinephrine and diphenhydramine (Benadryl). D. Explain to the client that these symptoms are normal responses to the medication.
ANS: B Although these are the expected physiologic responses to the preoperative medication, any time the client states that he or she can feel a change in normal cardiac function, the system should be assessed. If the client’s pulse and blood pressure are within normal limits, the nurse should
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3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. The nurse should: A. test the drainage for the presence of glucose. B. suction the nose to maintain airway clearance. C. document the findings and continue monitoring. D. apply a drip pad and reassure the patient this is normal.
A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF.
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A nurse is performing an assessment on a client who is at 38 weeks gestation and notes that the FHR is 174/bpm. On the basis of this finding, the appropriate nursing action is to: 1. Notify the physician 2. Document the findings. 3. Check the mother’s heart rate 4. Tell the client that the FHR is normal.
1. Notify the physican Rational: The FHR depends on gestational age and ranges from 160-170/bpm in the 1st trimester, but slows with fetal growth to 120-160/bpm near or at term. Because the FHR is increased from the reference range, the nurse should notify the physican.
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3 Nurses are mandated reporters of suspected child abuse. Significant bruising on a 2-year-old child’s head, arms, abdomen, and legs possibly indicate child abuse. It is not enough to document the findings, instruct the mother on safe handling of the child, or discuss the story with a colleague.
The home health nurse notices significant bruising on a 2-year-old child’s head, arms, abdomen, and legs. The patient’s mother describes the child’s frequent falls. Which is the best nursing action for the home health nurse to take? 1 Document the findings and treat the child. 2 Instruct the mother on safe handling of a 2-year-old child. 3 Contact a child abuse hotline. 4 Discuss this story with a colleague.
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