Question

U nu pumn u 4 on a pain scale of 1 to 10. 21. The client is diagnosed with gastroenteritis. Which laboratory data warrants immediate intervention by the nurse? 1. A serum sodium level of 152 mEq/L. 2. An arterial blood gas of pH 7.37, PaO2 95, PaCo2 43, HCO3 24. 3. A serum potassium level of 4.8 mEq/L. 4. A stool sample that is positive for fecal leukocytes 15 You are supervising a nursing student who is caring for a client who had a cholecystectomy. There is a T-tube in place. You would intervene if the student performs which action? 1. Maintains the client in o semi-Fowler position 2.Checks the amount, color, and consistency of the drainage 3.Gently aspirates the drainage from the tube 4.Inspects the skin around the tube for redness or irritation 13. You caring for a client who was admitted for advanced cirrhosis. The client has massive ascites peripheral dependent edema in the lower extremities, nausea and vomiting, and dyspnon related to pressure on the diaphragm. For the nursing diagnosis of Excess Fluid Volume, indicator is the most reliable for tracking fluid retention? a. Auscultating the lung fields for crackles every day b. Measuring the abdominal girth every morning c. Performing daily weights with the same amount of clothing d. Checking the extremities for pitting edema and comparing to baseline

Answer 1

21. 4. As presence of fecal leukocytes are indicative of inflammatory diarhea.

15. 3. As aspiration is not recommended

13. a. Auscultating lung for crackles every day