Answer to Question 1
A
A. Dialysate that is too cold results in intolerance, cramps, and hypothermia.
B. Place client in semi-Fowler's or high-Fowler's position. This position promotes optimal lung expansion.
C. Infuse the solution over prescribed time, usually 2 L/10-15 min.
D. Unclamp outflow tubing and drain, usually for 20 minutes.
Answer to Question 2
D
D. PCA allows more constant serum levels of the opioid and, as a result, avoids the peaks and troughs of a large bolus. Because the blood level is maintained within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced and the incidence of side effects, such as sedation and respiratory depression, is decreased.
A. Potential concerns involving PCA use are client-related, pump failure, or operator errors. Clients may misunderstand how PCA therapy works, mistake the PCA button for the nurse call button, or have family members who operate the demand button. Instruct family not to push timing device for the client unless client is unable to push the button himself or herself and the nurse has instructed family.
B. The pump may fail to deliver drug on demand, have a faulty alarm or low battery, or lack free-flow protection. Operators may incorrectly program the dose, concentration, or rate.
C. Assess client's cognitive ability to determine the appropriateness of client for PCA pain management.
Nurse-patient interaction; nonverbal communication
The nurse is using Standard Precautions to draw blood.
A nurse shows empathy to a client.
The surgical nurse assists the client into the correct position
Weber test: Place the base of the tuning fork on top of the client’s head.
Measuring the client’s height with a platform scale