Extra Evolve Resources for Test 2 - Part 2

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A client with a history of cardiac disease is taking a potassium-wasting diuretic (furosemide) and is seen in the emergency department for complaints of weakness. The nurse expects to evaluate which laboratory values?

Potassium and blood glucose levels

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Individuals taking potassium-wasting diuretics are at risk for

hypokalemia. Evaluating blood glucose level when the client reports weakness is important to ensure that low blood glucose level is not an issue.

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The 65-year-old client with congestive heart failure is at the greatest risk for

problems from fluid volume excess. Fluid overload in this client could quickly cause life-threatening problems.

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The 50-year-old client with second degree burns is at risk for

fluid volume deficit.

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The nurse anticipates that the physician will order which intravenous (IV) fluid for a client who is dehydrated?

0.45% Sodium chloride Because a 0.45% sodium chloride solution is hypotonic, water will move from the vein into the cells to help hydrate them

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A 3% sodium chloride solution is ___ and thus would cause water to move out of the cells into the cardiovascular space, which would dehydrates the cells.

hypertonic

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A 0.9% sodium chloride solution and Ringer's lactate solution are both __.

isotonic - They increase body fluid volume without causing a shift of water from one compartment to another.

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Thiazide diuretics cause the loss of

water and potassium through the kidneys.

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If A Thiazide diuretics client is not consuming sufficient potassium in the diet, a hypokalemic state could occur that can cause

muscle weakness and dysrhythmias.

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Hyponatremia is not usually a problem with Thiazide diuretics because

there is an abundance of sodium in the body and the additional regulation of sodium by aldosterone would compensate for sodium loss due to diuretics.

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Calcium level would be __ by thiazide diuretics.

unaffected

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If magnesium were to be affected by thiazide diuretics, it would be

excreted along with potassium, but the imbalance would be hypomagnesemia, not hypermagnesemia.

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PC02 Lab Values

35-45

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Telling

Outline the task to be done and gives explicit instructions – give them the overview in detail.

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The Healthy People 2010 initiative includes recommendations to improve

the dental health of the population of the United States. The goals for oral health are to decrease tooth loss caused by tooth decay or periodontal disease for people aged 35 to 44; reduce the number of older adults who have lost their natural teeth; redu

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The clients most in need of perineal care are those at greatest risk of

Acquiring an infection.

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Back rubs promote

relaxation, relieve muscular tension, and decrease the perception of pain.

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Audio books and snacks may provide

temporary comfort.

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Clients with conditions that pose greater risk to the integrity of the oral mucosa need more frequent mouth care to ensure that

the mouth is clean and free of infection.

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When providing oral hygiene to an unconscious client, the nurse should

position the client appropriately and use suction to ensure that there is no risk of aspiration. Good oral hygiene is still necessary to prevent mouth odor, dental caries, and ulcerations.

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A comfortable room temperature should be maintained for the client, about

20° to 23.3° C (68° to 74° F), depending on the client's comfort.

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Radiation therapy to the head and neck can impair

the secretion of saliva. Routine and frequent mouth care is essential. The nurse does not want to use mouth care products that contribute to further drying of the mucous membranes of the mouth. There is no reason that clients must remain NPO during radiat

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Proper oral care reduces

the bacterial count in oral secretions, which decreases the risk of bacterial pneumonia if oral secretions are aspirated.

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When assessing darkly pigmented skin for bruising, the nurse is sure to do which of the following?

Comparing sides of the body will allow the nurse to more easily see variations in skin color. Bruising will not appear red as in pink or white skin but will show variations of blue, purple, or gray. Fluorescent lamps can give the skin a bluish tone and th

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Hygienic care requires close contact with the client. The nurse initially uses which of the following to promote a caring therapeutic relationship?

Assessment skills, Fundamental skills, Communication skills

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A person's body image is

Social, Objective, Subjective, and Developmental

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Selling

2 way communication, Nurse paces instruction based on client’s feedback

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The nurse is gathering a sleep history from a client who is being evaluated for obstructive sleep apnea. What common symptom will the client most likely report?

The client will awake with a headache.

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The nurse teaches a client taking phenytoin (Dilantin), an anticonvulsant, that this group of medications causes which symptom of a sleep problem?

The anticonvulsants can cause increased daytime sleepiness because they decrease REM sleep time. They do not cause nocturia, increased awakenings, or increased difficulty falling asleep.

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Which intervention is appropriate to include on a care plan for improving sleep in the older adult?

By decreasing fluids 2 to 4 hours before sleep, it is less likely that the client will awaken because of a need to urinate. Limiting naps during the day will help improve nighttime sleep. The client should sleep until the same time each morning. Exercisin

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Babies should sleep on

their backs, not their stomachs, as a SIDS preventative. Babies should not be put to bed with a bottle. Due to nighttime feedings, new moms should be encouraged to temporarily place a cradle near where they sleep and know that they will have to get up dur

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The nurse is developing a plan of care for a client experiencing narcolepsy. Which intervention is appropriate to include on the plan?

Brief daytime naps of no longer than 20 minutes help reduce subjective feelings of sleepiness. Carbohydrates can increase sleepiness.

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Clients with obstructive sleep apnea are particularly sensitive to

opioids - risk of respiratory depression is increased. The nurse must recognize that clients with OSA should start out receiving very low doses of opioids.

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Which of the following medications are the safest to administer to adults needing assistance in falling asleep?

The safest group of drugs is the benzodiazepenes. They facilitate the action of the neurons in the central nervous system (CNS) that suppress responsiveness to stimulation, therefore decreasing levels of arousal. The other medications can be used, but lon

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The nurse recognizes that a client is experiencing insomnia when the client reports

Difficulty staying asleep, Extended time to fall asleep, and Feeling tired after a night’s sleep

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The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS), the best position in which to place the baby after nursing is

Supine and Side lying

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To assist an adult client to sleep better, the nurse recommends which of the following?

Consuming a small glass of warm milk at bedtime

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