(summary) Fundamentals ATI & RN 3.0, With
Complete Solution 2024.
a home health nurse is visiting an older adult client with severe dementia. the pt's son who is the
primary caregiver reports being exhausted from working part time and caring for his mother at home.
which should the nurse suggest?
a. rehabilitation
b. assisted living
c. respite care
c- respite care
-service for caregivers who need time to rest from multiple responsibilities related to the care of a family
member who needs assistance
-rehabilitation is for pt after and illness or injury (severe dementia will not improve with rehab)
a nurse is caring for a pt getting a blood transfusion. the pt states flank pain and has reddish brown urine
in the catheter bag. which of the following transfusion reactions is occuring?
a. hemolytic
b. febrile
c. circulatory overload
d. sepsis
a-hemolytic
Brainpower
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Hemolytic transfusion reaction
pt blood is incompatible with the donors blood
-chills
-low back pain
-hypotension
-tachycardia
Febrile hemolytic reaction
pt blood is sensitive to the WBC and platelets in the donors blood
-fever, chills, HA, flushing
circulatory overload reaction
blood is administered too quickly for the pt circulatory system to handle
-SOB (dyspnea, coughing, HA, HTN)
sepsis hemolytic reaction
,when blood is contaminated with bacteria
HIGH fever, vomiting, diarrhea
a nurse is evaluating the development of a group of pt. according to erikson the developmental task of
intimacy vs. isolation occurs during which of the following states of development?
young adulthood
-middle adulthood (generativity vs. stagnation)
-adolescence (identity vs. role confusion)
-childhood (industry vs. inferiority)
A nurse is changing the dressing for a pt who is 3 days post op. the nurse observes yellow, thick, drainage
on the dressing- what should she document this type of drainage as?
purulent exudate
serous drainage
-portion of the blood that is watery and clear/slightly yellow in appearance
ex: fluid inside of blisters
serosanguineous drainage
-plasma mixed with light blood drainage
-pale yellow to blood tinged
-can also be watery
sanguineous drainage
-RBC mixed with the plasma
-thick and reddish/bright red
bright drainage (fresh bleeding)
dark drainage (older bleeding)
, purulent exudate
-infection
-thick yellow, green, or brown drainage
-foul odor
purosanguineous exudate
newly infected wound
-mix of pus and blood
a nurse is calculating the protein needs of a client who weighs 132 lb. The RDA for protein for an adult
who has no medical conditions is 0.8 g/kg. how many grams of protein per day should the nurse
recommend for this pt?
a nurse is planning to assess the abdomen of a pt. which of the following should the nurse use first?
-inspection
-auscultation
-percussion
-palpation
inspection
a nurse is obtaining a capillary blood sample to determine blood glucose. the nurse punctures the pt
finger but does not get an adequate amnt of blood. which of the following should the nurse do next?
wrap the client's finger in a warm washcloth
(this helps increase blood flow to the client's finger)
-smearing a small amnt of blood onto the testing stip can lead to an inaccurate result
Complete Solution 2024.
a home health nurse is visiting an older adult client with severe dementia. the pt's son who is the
primary caregiver reports being exhausted from working part time and caring for his mother at home.
which should the nurse suggest?
a. rehabilitation
b. assisted living
c. respite care
c- respite care
-service for caregivers who need time to rest from multiple responsibilities related to the care of a family
member who needs assistance
-rehabilitation is for pt after and illness or injury (severe dementia will not improve with rehab)
a nurse is caring for a pt getting a blood transfusion. the pt states flank pain and has reddish brown urine
in the catheter bag. which of the following transfusion reactions is occuring?
a. hemolytic
b. febrile
c. circulatory overload
d. sepsis
a-hemolytic
Brainpower
Read More
Hemolytic transfusion reaction
pt blood is incompatible with the donors blood
-chills
-low back pain
-hypotension
-tachycardia
Febrile hemolytic reaction
pt blood is sensitive to the WBC and platelets in the donors blood
-fever, chills, HA, flushing
circulatory overload reaction
blood is administered too quickly for the pt circulatory system to handle
-SOB (dyspnea, coughing, HA, HTN)
sepsis hemolytic reaction
,when blood is contaminated with bacteria
HIGH fever, vomiting, diarrhea
a nurse is evaluating the development of a group of pt. according to erikson the developmental task of
intimacy vs. isolation occurs during which of the following states of development?
young adulthood
-middle adulthood (generativity vs. stagnation)
-adolescence (identity vs. role confusion)
-childhood (industry vs. inferiority)
A nurse is changing the dressing for a pt who is 3 days post op. the nurse observes yellow, thick, drainage
on the dressing- what should she document this type of drainage as?
purulent exudate
serous drainage
-portion of the blood that is watery and clear/slightly yellow in appearance
ex: fluid inside of blisters
serosanguineous drainage
-plasma mixed with light blood drainage
-pale yellow to blood tinged
-can also be watery
sanguineous drainage
-RBC mixed with the plasma
-thick and reddish/bright red
bright drainage (fresh bleeding)
dark drainage (older bleeding)
, purulent exudate
-infection
-thick yellow, green, or brown drainage
-foul odor
purosanguineous exudate
newly infected wound
-mix of pus and blood
a nurse is calculating the protein needs of a client who weighs 132 lb. The RDA for protein for an adult
who has no medical conditions is 0.8 g/kg. how many grams of protein per day should the nurse
recommend for this pt?
a nurse is planning to assess the abdomen of a pt. which of the following should the nurse use first?
-inspection
-auscultation
-percussion
-palpation
inspection
a nurse is obtaining a capillary blood sample to determine blood glucose. the nurse punctures the pt
finger but does not get an adequate amnt of blood. which of the following should the nurse do next?
wrap the client's finger in a warm washcloth
(this helps increase blood flow to the client's finger)
-smearing a small amnt of blood onto the testing stip can lead to an inaccurate result
