Verified Answers - (Verified Answers) 1. A client is admitted for ...

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MED SURG II HESI (Elsevier) 2023 (Verified Answers)

• A client is admitted for dehydration, and an intravenous (IV) infusion of

normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is:

• Discontinue the IV site and contact the primary health care provider

• Elevate the head of the bed and obtain vital signs

• Contact the primary health care provider to obtain a prescription for a

sedative

4. Assess for allergies and change the IV to an intermittent infusion device: -

ANS Elevate the head of the bed and obtain vital signs

• A nurse is assessing a client with a diagnosis of early left ventricular heart

failure. Specific to this type of heart failure, the nurse expects the client to

state: 1 / 2

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• "My ankles are swollen."

• "I am tired at the end of the day."

• "When I eat a large meal, I feel bloated."

• "I have trouble breathing when I walk rapidly: ANS 4. "I have trouble breathing

when I walk rapidly

• A client who had a myocardial infarction asks the nurse, "What's the chance

of my having another heart attack if I carefully watch my diet and stress levels?" What is the nurse's most appropriate initial response?

• Focus on the client's feelings by exploring the reason why the question was

asked.

• Explain that it is all right to be frightened and refer the client to the psychi-

atric nurse.

• Provide information that the client is correct in being especially careful in

these areas.

• Suggest that the client discuss follow-up care with the health care provider
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