Answer to Question 1
Correct Answer: 2
Rationale 1: Bibasilar crackles may develop secondary to fluid overload or to the disease process, but would not be particularly evident just after placement of the subclavian catheter.
Rationale 2: Because insertion of a subclavian central venous catheter may result in hemothorax, pneumothorax, cardiac perforation, thrombosis, or infection, the priority finding for planning care is tachycardia.
Rationale 3: Decrease in pedal pulses would not be associated with the placement of a subclavian catheter.
Rationale 4: Headache would not be associated with the placement of a subclavian catheter.
Answer to Question 2
Correct Answer: 1
Rationale 1: Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to health care providers for evaluation.
Rationale 2: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is juice the best choice of fluid.
Rationale 3: Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.
Rationale 4: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is glucose water the best choice of fluid.
The nurse assists the patient in reflecting on his feelings
A lumbar puncture. The needle is inserted between the lumbar vertebrae and into the spinal canal.
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
Using small, circular strokes, exfoliate the client’s neck and back.
Nurse using a stethoscope
A patient is talking to the nurse about her husband’s abuse and attempt to strangle her. She ...