A) Call the health care provider immediately
B) Administer acetaminophen as ordered as this is normal at this time
C) Send blood, urine and sputum for culture
D) Increase the client's fluid intake
A) Active and passive range of motion exercises twice a day
B) Every 4 hours incentive spirometer
C) Chest physiotherapy twice a day
D) Repositioning every 2 hours around the clock
These clients have a potential for an inability to have
voluntary and involuntary muscle movement or activity. Thus, options 1 and 2 are inadequate with this problem in
mind. Option 4 is not specific for prevention of complications associated with the lung.
A) Irritable and "colicky" with no attempts to pull to standing
B) Alert, laughing and playing with a rattle, sitting with support
C) Skin color dusky with poor skin turgor over abdomen
D) Pale, thin arms and legs, uninterested in surroundings
Diagnosis of NOFTT is made on anthropomorphic findings documenting growth retardation which would lead the nurse to expect muscle-wasting and paleness. In cases of NOFTT, the cause may be a variety of psychosocial factors and these children may be below normal in intellectual development, language and social interactions.
After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
The correct answer is A: Until the health care provider has determined that your ejaculate doesn''t contain sperm,
continue to use another form of contraception. All of these options are correct information. The most important point
to reinforce is the need to take additional actions for birth control.
A) Side-lying on the left with the head elevated 10 degrees
B) Side-lying on the left with the head elevated 35 degrees
C) Side-lying on the right wil the head elevated 10 degrees
D) Side-lying on the right with the head elevated 35 degrees
Gravity will draw the most blood flow to the dependent portion of the lung. For unilateral chest disease, it is best to
place the healthiest part of the lung in the dependent position to enhance blood flow to the area where gas exchange
will be best. Ventilation would be minimally affected in the right dependent lung. This position also enhances the
drainage of the infected part of the lung. An elevation of 35 degrees is counterproductive to therapeutic blood flow and
the drainage of secretions
A) difference in the intake and output B) changes in the mucous membranes C) skin turgor
The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A one-kilogram or 2.2 pounds of weight gain is equal to approximately 1,000 mls of retained fluid. Other options are considered as part of data collection, but they are not the most accurate indicator for \u2018fluid balance.
D) Announce a cardiac arrest, and assist with intubation
The correct answer is A: Stay with client and observe for airway obstruction
For the client\u2019s safety, remain at the bedside and observe respirations and level of consciousness. Prepare to clear the
A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse\u2019s initial evening
rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation.
Which statement would alert the nurse to a complication?
A) "I have a sharp pain in my chest when I take a breath."
B) "I have been coughing up foul-tasting, brown, thick sputum."
C) "I have been sweating all day."
D) "I feel hot off and on."
Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client is grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for infections.
The correct answer is D: I went to the bathroom and my urine looked very red and it didn\u2019t hurt when I went. With
this history this client needs to be seen that day since painless gross hematuria is closely associated with bladder cancer.
The other complaints can be handled over the phone.
A) S3 ventricular gallop
B) Apical click
C) Systolic murmur
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