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The nurse is assessing a client with a sodium level of 138 mEq/L (135-145 mEq/L), bounding pulses, blood pressure of 159/92 mmHg, pedal edema and confusion. Indicate which prescriptions ordered by the provider and nursing actions are essential, non-essential, or contraindicated.

A.

Assess for symptoms of hyperglycemia

B.

Assess for bilateral peripheral edema.

C.

Measure intake and output every hour.

D.

Review the client's most recent CBC results.

E.

Hold furosemide

F.

Place the client in Trendelenburg position

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"}}

  • Assess for symptoms of hyperglycemia – Non-essential: The client’s presentation is consistent with fluid overload and hypertension, not hyperglycemia. Assessing for hyperglycemia may be done but is not a priority.
  • Assess for bilateral peripheral edema – Essential: Bilateral edema is a key indicator of fluid overload and cardiovascular compromise, requiring immediate assessment.
  • Measure intake and output every hour – Essential: Accurate I&O monitoring is critical for managing fluid status in clients with edema and hypertension.
  • Review the client's most recent CBC results – Non-essential: While helpful for general assessment, CBC does not directly address the acute fluid overload and cardiovascular status.
  • Hold furosemide – Contraindicated: Furosemide, a loop diuretic, is typically indicated for fluid overload. Holding it could worsen edema and hypertension.
  • Place the client in Trendelenburg position – Contraindicated: Trendelenburg can increase venous return and worsen pulmonary edema or hypertension, making it unsafe for this client.


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Related Questions

Correct Answer is A

Explanation

A. Clients with cholecystitis should follow a low-fat diet and avoid fried, greasy, or high-fat foods to reduce gallbladder stimulation and prevent painful episodes.
B. A diet high in cholesterol and salt worsens gallbladder disease and is not recommended.
C. Eggs and cheese are high in fat and can trigger biliary colic.
D. A high-calorie, low-protein diet is not appropriate and may worsen maternal and fetal outcomes.

Correct Answer is ["A","C","D","E"]

Explanation

A. Newborns cannot shiver effectively to produce heat until around 3 months of age, making them more vulnerable to cold stress.
B. Newborns do not have a small surface area to body mass ratio; instead, they have a large ratio, which increases heat loss.
C. Limited voluntary muscle activity reduces their ability to generate heat through movement.
D. Newborns have only limited metabolic reserves (glycogen, glucose, fat), making it harder for them to sustain thermogenesis.
E. A large surface area relative to body mass increases susceptibility to heat loss through radiation, conduction, convection, and evaporation.

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