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1. 1. A male client with stomach cancer returns to the
unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's
solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood
in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg.
In addition to reporting the finding to the surgeon.
Which action should the nurse implement first?
2. 2. an adult male who fell 20 feet from the roof of this
home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction
control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal,
and over the past hour 75 ml of bright red blood is
measured in the collection chamber.Which intervention should the nurse implement?
3. 3. A client who received hemodialysis yesterday is
experiencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate 36
breaths/minute.The client is manifesting shortness
of breath, bilateral 2+ pedal edema, and an oxygen
saturation on room air of 89%. Which action should
the nurse take first?
4. 4. A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based
on the client's admitting diagnosis, which findings
require immediate action by the nurse? (Select all
that apply)
5. 5. An older client is admitted with fluid volume deficit
and dehydration.Which assessment finding is the
d. Increase the infusion rate of Lactated Ringer's solution.
a. Add sterile water to the suction
control chamber.
c. Begin supplemental oxygen.
Headache and
tremors
Irregular heart
rate
pallor and diaphoresis
d. Skin tenting
occurs when the
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