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An older adult client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (Please scroll and view each tab’s information in the client’s medical record before selecting the answer.) Reference Range: Sodium [136 to 145 mE/L (136 to 145 mmol/L)] Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] Chloride [98 to 106 mE/L (98 to 106 mmol/L)] pH [7.35 to 7.45] PaCO2 [35 to 45 mm Hg] HCO- [21 to 28 mEq/L (21 to 28 mmol/L)] Pa02 [80 to 100 mm Hg] • A Give a bolus of 0.9% sodium chloride 1,000 mL over 30 minutes. • B Begin potassium chloride 10 mEq over 1 hour per secondary infusion. • C Initiate continuous dopamine infusion at 2 mcg/kg/minute. • D Administer promethazine 25 mg slow IV push every 4 hours. (2) An adolescent who was diagnosed with type 1 diabetes mellitus at the age of 9, is admitted to the ho cause of the ketoacidosis? A Had a cold and ear infection for the past two days. B Ate an extra peanut butter sandwich before gym class. C Incorrectly administered too much insulin. Skipped eating lunch while at school. (3) The nurse is caring for a client with pneumonia who now develops initial signs of septic shock a protocol. Which intervention is most important for the nurse to include in the plan of care? • A Monitor blood glucose level. • B Keep head of bed raised 45 degrees. • C Assess warmth of extremities. • D Maintain strict intake and output (4) A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPL immediate intervention to reduce the likelihood of harm to this client? Select all that apply. A The client is lying in a supine position in bed. B A low sodium diet tray was brought to the room. C A bedside commode is positioned near the bed. D A saline lock is present in the right forearm. E A full pitcher of water is on the bedside table. (5) The nurse on the medical-surgical unit is receiving a transfer report from the postanesthesia care unit (PACU) nurse for a c PACU nurse provides the following information: “1,000 mL 0.9% sodium chloride is infusing at 125 mL/hr into the left wrist v every 8 hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain at a a prescription for hydromorphone 1 mg IV every 2 hours PRN for pain. The last dose was administered at 1000.” Which ado report? • A Peripheral pulses present with full range of motion of both legs. • History of vomiting at home for 3 days prior to surgery Declining to take ice chips despite reporting of dry mouth. • D Soft abdomen, absent bowel sounds, no bleeding on dressing. (6) The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. Th sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care? • A Maintain strict intake and output. • B Monitor blood glucose level. • Keep head of bed raised 45 degrees. D Assess warmth of extremities.
SCIENCE
HEALTH SCIENCE
NURSING
NURSING SURGICAL N

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