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a client diagnosed with cirrhosis is experiencing pruitus. which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity?
1. maintain short fingernails to minimize excoriating the skin
2. take a bath or shower in hot water to alleviate itching sensations
3. take prescribed cholestyramine 1 hour after other medications
4. use a moisturizing cream on unbroken skin daily
5. wear wool gloves and tight stockings to avoid scratching
1, 3, 4
the nurse has attended a staff education program about physical assesment of the renal system. Which of the following statements by the nurse would indicate a correct understanding of the program?
1. "dark brown urine may indicate that the client has a UTI
2. "i should be able to palpate both kidneys regardless of the clients abdominal girth"
3." the bladder should be nontender and nonpalpable when it is empty "
4. I will assess for tenderness of the kidneys by performing blunt percussion over the clients lower abdomen
3
a nurse caring for a client with a cvc enters the client's room and notes that the cvc is dislodged and lying in the client's bed linens. The client appears cyanotic and is tachypneic and diaphoretic. which of the following actions by the nurse are appropriate ?
1. administer o2 via non rebreather mask
2. apply an occlusive dressing over the insertion site
3. assist the client to high fowler position
4. monitor vital signs and respiratory effort
5. notify the hcp
1,2,4,5
the nurse is providing postoperative care to a client who had a laparoscopic cholecystectomy 4 hours ago. Which intervention is the priority ?
1. apply antiembolism stockings
2. assist with early ambulation
3. encourage a low fat diet
4. offer stool softeners
2. Assist with early ambulation
the nurse is caring for a client receiving peritoneal dialysis. which findings are essential for the nurse to report to the hcp ?
1. cloudly outflow
2. low grade fever
3. oliguria
4. pruitus
5. tachycardia
1, 2, 5
which would be the appropriate client criteria for activating a rapid response team at the hospital ? select all that apply
1. gcs score of 9 throughout shift
2. heart rate remaining at 58 beats/min for more than 1 hour
3. post op pain rated at 10
4. respiratory rate maintaining an increase to 30 breaths/ min
5. sustained change in level of consciousness for 10 mins
4, 5
the nurse is screening clients for those at risk for developing acute pancreatitis. which of the following factors would increase a clients risk for developing acute pancreatitis
1. abdominal trauma
2. alcohol use disorder
3. excess calcium intake
4. untreated cholelithiasis
5. elevated uric acid level
1, 2, 4
a client diagnosed with ESRD comes to the dialysis clinic for treatment. which actions should the nurse take to prepare the client for hemodialysis?
1. administer sub q heparin to decrease clotting during dialysis
2. administer the clients morning doses of carvedilol and lisinopril
3. check the clients meidcal records to determin the last post dialysis weight
4. obtain a set of client vital signs and the clients current weight
5. palpate the fistula in the clients arm for a thrill and auscultate for a bruit
3, 4, 5
How do you measure the length of an NG tube for proper placement?
nose, ear, xyphoid process
1. A nurse is caring for a client with cirrhosis who is showing signs of confusion. Which laboratory value is most important for the nurse to assess?
2. The patient is also exhibiting a “flapping hand tremor.” What is the medical term for this finding?
1. Ammonia level
2. Asterixis
what medication is given usually given during dialysis, for patient in ESRD, that treats anemia? and how does it treat anemia
Epoetin alfa is a synthetic form of erythropoietin, a hormone normally produced by the kidneys. It stimulates the bone marrow to produce red blood cells, correcting anemia caused by decreased natural erythropoietin production in ESRD.
What are the gauge sizes of IV catheters for the following colors?
Pink
Blue
Green
Which IV catheter should not be used if the patient is going to receive a blood transfusion?
20
22
18
; blue 22 guage