Answer to Question 1
ANS: A, B, D, E
Lungs should be auscultated to detect the presence of fluid as a result of heart failure. Skin turgor is directly related to the degree of hydration. Skin that is well hydrated is elastic and rapidly returns to a flat position after being pinched. In dehydrated patients, the skin remains in a peaked or pinched position and returns very slowly to the flat, normal position. Positioning techniques are essential to avoid skin breakdown resulting from edema or dehydration. Assessment of intake and output will assist in determining the effectiveness of diuretic therapy. The health care provider, not the nurse, will determine the need for electrolyte supplementation. When ordered, the nurse will administer the appropriate replacements. Maintaining the ordered diet therapy is within the role of the nurse.
Answer to Question 2
ANS: C
The level indicates hypokalemia and could worsen with the administration of a loop diuretic; therefore, the dose should be withheld. Crackles, peripheral edema, and weight gain do not warrant withholding the medication.
The nurse can make observations about the patient's general appearance while talking with the p
Symptoms of a patient in shock.
Domains of nursing practice
Patient Teaching Methods Cont.
Nursing Interventions According to Stage of Severity for Suicide Risk
Hands-on class in a massage therapy program.