Exam 2 NR 341 CATS

1.The nurse is caring for a client with hypovolemic shock. The family member asks why the fluids are being warmed. What is the best response by the nurse?  “to prevent complications from hypothermia” 2.The nurse is caring for a newly admitted client diagnosed with acute kidney injury. The nurse understands that the acute kidney injury is most likely related to a history of which condition?  Sepsis 3.The nurse is caring for a client being monitored by arterial pressure monitoring. The nurse notes a systolic pressure of 164 mmHg. What action should the nurse take first?  Assess the client. 4.The nurse is caring for a client with an arteriovenous (AV) fistula. Upon assessment, the nurse is unable to auscultate a bruit. What action should the nurse take first?  Notify the provider 5.The nurse is assessing jugular venous pressure. In what order should the nurse proceed with the steps in the process? [place the steps in the correct order beginning with the first step]  3.place head of bed between 30-45 degrees.  2. Have client turn head slightly to the left.  6. Shine a pen light across the neck, assess for jugular venous distension at end of exhalation.  5.observe the highest point of pulsation in the internal jugular vein at end exhalation.  4. Measure the vertical distance between the pulsation and the angle of louis.  1. Add 5 cm to the measurement. 6.The nurse is caring for a client with acute kidney injury. The nurse should anticipate which abnormal assessment finding?  BUN/creatinine ration 25.1 7.The nurse is caring for a client whose vital signs are monitored using invasive hemodynamic monitoring. Which action is most important for the nurse to implement to decrease the risk of infection?  Strict hand washing 8.The nurse is preparing a client for placement of a catheter for arterial pressure monitoring. What is the best way for the nurse to assess ulnar circulation prior to catheter insertion?  Occlude the radial artery.