- A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. Precipitous decrease in serum creatinine levels C. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min & to report back in 1 hr. Which of the following actions should the nurse take next? A nurse is caring for a client who has vision loss. Oxygen saturation is 93% on room air. Do not administer any further medication. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has suspected appendicitis. Increase consumption of citrus fruits and strawberries. Cardiac distress, The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock . List the steps in the order that they occur. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? A. Respiratory obstruction 2. " "I will resume taking my prenatal Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a postoperative client at risk for hypovolemic shock. Which of the following actions should the nurse take next ? A postpartum nurse is caring for a client who has developed hemorrhagic shock. Reported pain lvl E. 5 C. Tachycardia C. Study with Quizlet and memorize flashcards containing terms like When analyzing assessment data, the nurse recognizes that which of the following puts client at risk for hemorrhagic shock? A. The 33-year-old male client is awake, alert, and moves all extremities well. Which of the following pieces of interview data could be an influence on this high body temperature? a- the client has just run 4. Question: A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. Blood transfusion, The nurse expects to find the client receiving chemotherapy for a brain tumor exhibiting which signs and symptoms Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is 8 hr postoperative following an abdominal hysterectomy. Hemoglobin 8. 2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. 2 C (99 F). Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a postoperative client at risk for hypovolemic shock. Which assessment indicates an early sign of shock? a. Encourage the client to drink iced liquids. Which are local complications? Select all that apply. Physiology d. Which of the following actions should the nurse take next ? Study with Quizlet and memorize flashcards containing terms like A nurse is caring fro a client who is postoperative and has signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr Which of the following actions should the nurse take next Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is postoperative following abdominal surgery. The nurse notifies the surgeon, who tell the nurse to continue the client's vital signs every 15 min and to report back in 1 hr. 2°F (38. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. International normalized ratio (INR) 7. The results of this test will allow the nurse to assess which aspect of the client's health? A. Heart rate 120 beats/min, Which client demonstrates the highest risk for hypovolemic shock? A. Blood pressure 100/48 mm Hg B. Early recognition and appropriate management are essential. Within 6 hours of being admitted Study with Quizlet and memorize flashcards containing terms like A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following actions should the nurse take next? Study with Quizlet and memorize flashcards containing terms like The nurse is assessing clients for postoperative complications. C. Confirm unresponsiveness. 8 degrees F). Which assessment indicates an early sign of shock? Blood pressure 100/48 mm Hg Respiratory rate 12 breaths/min First-degree heart block Heart rate 120 beats/min, Which client demonstrates the highest risk for hypovolemic shock? Client receiving a blood Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with aortic regurgitation. Study with Quizlet and memorize flashcards containing terms like The nurse cares for clients with obesity and understands that causes are multifactorial. Avoid milk and milk products. b. . Which of the following actions should the nurse take next?, A nurse is caring for a client who has Study with Quizlet and memorize flashcards containing terms like A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. Initiation of reverse peristalsis in the stomach 2. Urinary output D. Offer the patient fluids. document provider Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Wound infection 3. Which of the following are signs and symptoms consistent with that Study with Quizlet and memorize flashcards containing terms like The nurse is aware that the client with a brain tumor can be medically managed with which treatments? Select all that apply. Encourage the client to practice relaxation techniques Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Fine crackles A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. First-degree heart block D. Platelets 170,000 D. Which of the following steps should the nurse identify as the first response when performing CPR? Call for assistance. To deselect a finding, click on the finding again. Report observation to the health Neurovascular system Explanation: The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Surgery 4. Which of the following information should the nurse include?, A nurse is preparing an in-service about vital signs for a group of newly hired AP. Begin chest compressions. Hypotension unresolved by fluid administration D. 3. Diminished deep tendon reflexes B. Identify the sequence in which the nurse should perform the following steps. Which of the following manifestations would the nurse expect? A. 2 g, The nurse is caring for postoperative clients at risk for hypovolemic shock May 30, 2023 · The reason why the nursing manager should be notified is that hemorrhagic shock is a severe condition that requires immediate medical attention, and the surgeon's instruction of monitoring the client's vital signs for an hour is not sufficient to meet the patient's needs. Which of the following pieces of documentation is correct? A. Which of the following interventions should the nurse plan to include? 1. Limit snacking between meals B. Glucosuria, The . Click to highlight the assessment findings below that the nurse should report to the provider. Radiation 3. 82 km (3 miles) outside before coming to the interview b- the client drinks 8 glasses of water a day c- the client The nurse in a community health clinic performs a comprehensive assessment on a new client. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia? Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. Respiratory rate 24 C. Which of the following entries in the chart requires follow up by the nurse? BP 130/82 mm Hg left arm, lying. Partial thromboplastin time (PTT) 12. SaO2 97% right index finger, room air D. What is the most commonly assessed postanesthesia recovery emergency? 1. Instruct the client to increase exercise. Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a client for local complications of intravenous therapy. [1] Hypovolemic shock is circulatory failure due to effective intravascular volume loss (fluids or blood). Which of the following methods of Study with Quizlet and memorize flashcards containing terms like The nurse is providing care for a client who had surgical repair of a paraesophageal hernia. Which recommendation should the nurse make for change in the diet? A. Taper down interventions slowly when the prognosis worsens. If left untreated, hypovolemic shock can lead to ischemic injury of vital A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. A nurse is caring for a client who has been prescribed a potassium wasting diuretic medication. First-degree heart block b. ATI - Test 6 Practice Assessment. What nursing intervention takes highest priority?, The A nurse is caring for a client who is postoperative following abdominal surgery. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who is experiencing tachycardia. Which of the following actions should the nurse take next? Study with Quizlet and memorize flashcards containing terms like The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Desired Outcome: The patient will exhibit adequate tissue perfusion as evidenced by normal vital signs, presence of strong peripheral pulses, warm and dry skin, and acceptable urine output. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38. Immunology, A nurse cares for an older adult client with obesity who also has glaucoma. The nurse observes that the patient exhibits signs of dysphagia during the first postoperative meal. Cut the food into small pieces. Which of the following strategies should the nurse plan to use while caring for the client? 1. Nursing Diagnosis: Risk for Altered Tissue Perfusion related to post-operative nursing care. The client reports burning when urinating. Which of the following manifestations should the nurse expect?, A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. a nurse is caring for a client who is postoperative and is exhibiting signs of the hemorrhagic shock. The RN who Study with Quizlet and memorize flashcards containing terms like A Nurse is preparing an in service about factors affecting respiratory rates for a group of assistive personnel. 9° C (100. surgery The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains. Assess the client's level of anxiety and provide emotional support. Blood pressure 100/48 mm Hg c. The nurse should recognize which of the following Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing documentation of vital signs by a newly licensed nurse. Study with Quizlet and memorize flashcards containing terms like A nurse is monitoring a client who recently had a cast placed on his lower extremity for a bone fracture. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. Weigh the client monthly D. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock . Which statement describes priorities the nurse should establish while performing the physical assessment? a. Administer opioid analgesics. Which action does the nurse take? A. The RN who Study with Quizlet and memorize flashcards containing terms like A client has an oral temperature of 37. 4°C); heart rate, 100 beats/min; blood pressure, 90/60 mm Hg. Which of the following info should the nurse include about measuring Study with Quizlet and memorize flashcards containing terms like Which nurse would be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? A. Which of the following interventions should the nurse perform to prevent respiratory complications? A- instruct the client to exhale into the incentive spirometer every 1 to 2 hr. When planning this client's care, the nurse would expect to administer what priority medication?, The nurse is providing care for a client who is unconscious. Protein b. The client asks the nurse about birth control. Keep the door to the client's bathroom slightly ajar. Decrease amount of fluids containing caffeine. The client feels tired and has a productive cough. The new RN who recently finished orienting and is working independently with moderately complex clients C. ) "I am likely to have a fever during the first week I am home. Provide decaffeinated beverages A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she has a sudden, severe headache and vomiting. The plan of care includes assessment of specific gravity every four hours. Client A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. which of the following actions should the nurse take next? A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The LPN/LVN who has 20 years of experience B. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Q. Schedule regular nap times during the day C. The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vitals signs every 15 min and to report back in 1 hr. Which of the following nursing actions is appropriate? a) Prepare to stay with the client's body after death until family arrives b) Arrange for a member A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. Dehydration 4. Chemotherapy 2. The nurse is reviewing the client's lab values and notes that the client's calcium levels have increased since before the surgery. Heart rate 120 beats/min, Which client demonstrates the highest risk for hypovolemic shock? a. Genetics e. " What action by the nurse can assist the client with alleviating the discomfort associated with gas? Encourage the client to ambulate. Place the client in a flat position with legs elevated 45 degrees. The nurse knows to expect which of the following symptoms on physical examination? a) Orthopnea and dyspnea b) Nausea and low urine output c) Headache and vomiting d) Increased urine output, The nursing priority of care for a client exhibiting signs and symptoms of The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information:Physical Assessment FindingsDiagnostic FindingsPulse 140 beats/min and threadyABG respiratory acidosisBlood pressure 60/40 mm HgLactate level 63 mg/dL(7 mmol/L)Respirations 40/min and shallowAll of these provider prescriptions are given for the client. Contraction of abdominal muscles 3. Deep abdominal breathing C. , A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Neuro Assessment B. Respiratory rate 12 breaths/min C. Client Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Cool nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. Which of the following actions should the nurse take first?, A nurse is preparing to apply a condom catheter to a client who has a penis. Vitamin B1 d. A. GI Assessment F Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is postoperative & exhibiting signs of hemorrhagic shock. From the legal perspective, which of the following actions should the nurse taking next? A. , A nurse is caring for a client who requires a A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. Continual cardiovascular assessment is important but not the main focus of asses Study with Quizlet and memorize flashcards containing terms like The nurse is assessing a client suspected of having developed acute glomerulonephritis. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vitals signs every 15 min and to report back in 1 hr. Prepare the client for pulmonary A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. What is the priority nursing intervention for this client? Remove extra coverings on the client to keep temperature down. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min & to report back in 1 hr. Blood pressure 132/86 mm Hg, A nurse is planning care for a group of clients and is delegating to the assistive Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client admitted with a diagnosis of acute kidney injury. 1) obtain the pronouncement of death from the provider 2)remove the tubes and indwelling lines 3) wash the client's body 4) ask the client's family if they would like to view Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion. Calcium c. The nurse understands these symptoms to be suggestive of which of the following findings?, A client is hospitalized when presenting to the emergency department with right-sided weakness. Closure of the trachea to prevent aspiration 4 A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. The brain MRI reveals an infarct. 1. B- Minimize the amount of pain medication the client receives to prevent sedation. Warm, dry hands with prompt capillary refill Study with Quizlet and memorize flashcards containing terms like A client is admitted with weakness, expressive aphasia, and right hemianopia. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. Bone marrow transplant 5. Vitamin D, A nurse is assessing a client who has a pressure ulcer. Client reports experiencing postoperative pain as 7 on a scale of 0 to 10. Which assessment indicates an early sign of shock? A. The nurse interviews the client. The nurse has attempted to assess his temperature using an oral thermometer but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Pulse 52/min B. 2 degrees Celsius (100. Which of the following actions should the nurse include in the plan? A. The nurse should prioritize assessment for what health problem? A. Environment c. When the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hour. when the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. Weak and irregular pulse D. This effective circulatory volume loss leads to tissue hypoperfusion and tissue hypoxia. Which of the following findings should the nurse recognize as abnormal?, A nurse is caring for a client who has a history of breast cancer. Respiratory rate 12 breaths/min d. 2. from a legal perspective, which of the following actions should the nurse take next? 1. Behavior b. Which of the following methods should the nurse identify as the most reliable for verifying placement of the Study with Quizlet and memorize flashcards containing terms like Which nurse would be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? A. What action should the intensive care nurse include during this phase of the client's care? a. When caring for this client, the nurse recalls that the vomiting reflex follows a set pattern. Nutritional status B. Vital signs include: temperature, 101. The nurse notifies the surgeon , who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr . 9 B. Which obesity Study with Quizlet and memorize flashcards containing terms like A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who is vomiting. a. Communicate clearly and frequently Jun 5, 2023 · Hypovolemic shock is a potentially life-threatening condition. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply. The client's medical record states that the client is a practicing Roman Catholic. urinary output of 40 mL/hour B. Touch the client before speaking and after entering the room. B. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 minutes and to report back in one hour. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. Give rescue breaths. Hematuria B. What factors contribute to the development of obesity? Select all that apply. Which of the following actions should the nurse take? Choose matching definition An 86-year-old male client with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. Vital signs are: temperature: 37. Stand just ahead of the client and offer an arm for guidance during A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Incisional drainage C. Which of the following nutrients should the nurse include in the teaching? a. Potassium balance C Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a postoperative client at risk for hypovolemic shock. A nurse is planning care for a client who has vegetative signs of depression. Instruct the client to consume no more than four caffeinated beverages per day. bbsd mpxrb hipk beruozr uvxhx qtq axobv hpgr slvkg gjwxxw