Question

1. A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include?

1. Measure vital signs every 4 hr.
2. Position the client on the left side.
3. Initiate a continuous IV heparin infusion.
4. Instruct the client to massage the lower extremities.

2. A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?

1. Decreased erythrocyte sedimentation rate
2. Elevated serum calcium
3. Decreased serum amylase
4. Elevated blood glucose

3. A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take?

1. Leave unused equipment in the client's room until discharge.
2. Move the client's soiled linens to a designated container outside the room.
3. Attach a dosimeter badge to the client's gown.
4. Place long handled forceps at the client's bedside.

4. A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

1. Pitting, dependent edema
2. Increased blood pressure
3. Decreased blood pressure
4. Distended Jugular veins

Answer 1

Ans 1) nurse initiate a continuous iv heparin infusion because early treatment to breakup the clot greatly reduces risk of death and this can be done by heparin (blood thinner)

Heparin works by activating antithrombin to reduce the size of pulmonary embolism and prevents the clots to become larger

Measurement of vital signs in every 4 hrs and instruct the client to massage the lower extremities

Ans 2) in the laboratory reports of a clientwhonhas caute pancreatitis

(1) increased blood sugar levels- because damage to insulin producing cells in pancreas decrease the insulin level in blood

Serum calcium level decreases -in pancreatitis because pancreas is damaged and free fatty acid are generated bye the action of pancreatic lipase , insoluble ca salts present in pancreas so fatty acid chelate with ca salts and resulting ca deposition in retroperitoneum

Serum amylase increased -in acute pancreatitis because acute inflammation and auto digestion of pancreas leads to the release of both amylase and lipase

Increased ESR can predict severe Acute pancreatitis

Ans (4) by decresed blood presure and absense of jugular venous distension client can demonstrate the patient with dehydration and in early age pitting or dependent edema also present in patient with dehydration