Answer to Question 1
A
A. Client's ideal weight gain is usually between 1 and 2 pounds per week
B and C. Serum electrolytes are out of normal rangemay indicate movement of electrolytes in response to infusion of fluids and glucose. The electrolyte levels in the solution may need to be adjusted.
D. Serum glucose levels are less than 200 mg/100 ml.
Answer to Question 2
D
D. Restraints should be removed at least every 2 hours. If client is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints.
A and B. Observation and frequent assessments prevent complications, such as suffocation, skin breakdown, and impaired circulation.
C. If nurse restrains client in emergency situation because of violent or aggressive behavior that presents an immediate danger, a face-to-face physician assessment within 1 hour is needed.
Client position when assessing jugular vein distention.
Nurse's hand over patients abdomen
Nutrition Bar
Testing client’s ability to identify sharp sensations
Position the client
Client is positioned