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CC Case 2 pg101 fluid overlaod with acute renal failure

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Professor Johanna Ramirez

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What should be the nurse's first action after placing Alfred in the hospital gown? 

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TRIAGE ASSESSMENT: Temp 97.2, HR 110, BP 122/75 MAP (91) O2 sat 91% room air. Glucose 240 A&Ox3 Lungs bilateral crackles, in bilateral lower posterior lobes and noted in upper bilateral posterior lobes, moist cough, 3+ pitting edema. Name the Top 3 priority assessments? 

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What would the nurses priortiy nursing action be?

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Place these orders in the correct order. 

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The nurse reassess the oxygen saturation reading after 15 minutes and it is 89%. What should the nurse do next?

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The chest x-ray is completed. The radiologist calls the nurse to say "the lungs have fluffy consolidation bilaterally" How should the nurse interpret this report? 

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The nurse evaluates the clients response to furosemide. Which finding determines the dose was effective? 

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What hypothesis can the nurse make from the lab values and chest x-ray report? Labs: HGB 8.5, Potassium 6.0, BUN 32, Creatinine 3, WBC 6.2

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What should the nurse include in Alfredo's pland of care? Select all that apply! 

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Alfredo is admitted to the medical unit for dypnea and renal failure and a 24 hour urine is ordered. What should the nurse include in her teaching ? Select all that apply

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Alfredo's condition is worsening what potential complications should the nurse be monitoring for? Select all that apply.

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It was determined that Alfredo will be started on hemodialysis with a temporary dialysis catheter in his right internal jugular. What should teh nurse assess wiht type of access? Select 2 answers.

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What medications should the nurse hold prior to dialysis ? Select all that apply. 

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Alfredo returns from dialysis but is sleepy, A&O4 vitals 89/45 (60), glucose 65, HR 115 O2 Sat 96%. What actions would you take as the nurse? Select 2 choices.

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Alfredo begins to improve and the nurse is preparing discharge instructions which ones should the nurse prioritize?

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