Vn 15 Test 5

Question 1

1. Understand manifestations, nursing actions, and priorities for hypovolemia.

Answer 1

Manifestations
-Tachycardia
-Thready pulse
-Hypotension
-Dry mucous membranes
-No change in lung sounds
Nursing actions
-Increase oral intake
-Administer IV fluid replacements
-Controlling fluid losses
-Use a combination of the list above
Priorities
-Increase fluid

Question 2

When should colloid be used?

Answer 2

when a patient needs substances such as blood and blood products (such as albumin)

Question 3

When should crystalloid be used

Answer 3

made of water and other uniformly dissolved crystals(salts and other water-soluble molecules)

Question 4

When should isotonic be used?

Answer 4

contains the same concentration of dissolved substances as normally found in plasma (used for hypotension, hemmorrhage, calories(fluid volume))

Question 5

When should hypotonic be used?

Answer 5

. contains fewer dissolved substances that normally found in plasma (used in hypernatremia (cells swell))

Question 6

When is hypertonic used?

Answer 6

is more concentrated than body fluid and draws cellular and intital water into the intravascular compartment (given to a patient with edema (cells shrink).

Question 7

3.Understand manifestations, nursing actions, and priorities for hypervolemia

Answer 7

Manifestations
-Bounding pulse
-Hypertension
-Moist mucous membranes
-Crackles in lungs
-Pitting edema

Nursing actions
-Restricting or limiting oral fluids
-Reducing salt consumption
-Dc IV fluid infusions or reducing the infusion volume
-Admin. Drugs that promote urine elimination
-combination of the above interventions

Priorities
-Decrease fluids

Question 8

4. Understand the three phases of the nurse-client relationship and be able to identify examples.

Answer 8

Introductory phase
-Period of getting aquainted

Working phase
-Mutually planning care, implementing plan

Terminating phase
-Nurse and client agree immediate health problems have improved

Question 9

5. Understand and identify examples of the following therapeutic communication techniques provided in your Brightspace handout.

Answer 9

-giving broad openings
-exploring
-accepting
-offering general leads
-giving recognition
-giving information
-seeking clarification
-verbalizing the implied
-using silence
-offering self
-making observations
-Placing the event in time or sequence
-encouraging compassion
-reflecting
-restating
-summarizing

Question 10

6. Understand and identify non-therapeutic techniques: see slide 8 in PP.

Answer 10

• Giving advice
• Minimizing or discounting feelings
• Deflecting
• Interrogating- “why”
• Sparring

Question 11

7. Review key points in the Muslim and Asian culture (from presentations)
   Asian Americans

Answer 11

Asian Americans
• believe that lingering eye contact is an invasion of privacy or a sign of disrespect.
• feel more comfortable with the nurse at more than an arm’s length away
• consider the head to be a sacred body part that only close relatives can touch. ask permission before touching this area.
• Asians also believe that the area between a female’s waist and knees is particularly private and should not be touched by any male other than the woman’s husband. a male nurse offering an explanation, requesting permission, and allowing the client’s husband to stay in the room
Arab Americans
• may misinterpret direct eye contact as sexually suggestive.

Question 12

8. What are nursing considerations when monitoring TPN via infusion pump?

Answer 12

Watch out for
-Infiltration
-Phlebitis
-Lipid emulsions: watch for reactions m