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A 94-year-old patient is receiving gentamicin sulfate (Garamycin) in a continuous intravenous (IV) infusion. The nurse adds to the nursing care plan the diagnosis “Risk for decreased sensory perception.” What nursing action should be implemented?

You are performing CPR on a individual: how fast are the chest compressions and what is the ratio of compressions to breaths?

The nurse reviews the admission notes and nurse’s notes. Chief Complaint:The patient reports feeling fatigued and experiencing frequent headaches for the past week. They also report generalized muscle weakness, which has worsened over the past few days. The patient notes that they have gained approximately 6 pounds (2.72 kg) over the last 5 days and states, “I need to sleep in my recliner at night because lying flat makes it hard to breathe.” Past Medical History: Hypertension Type 2 Diabetes Mellitus CHF Vital Signs at Admission: Blood Pressure: 120/80 Pulse: 104 bpm (apical, regular) Respiratory Rate: 24 breaths/min Temperature: 98 oral O2 Saturation: 95% RA Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. fatigue and headache _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. muscle weakness _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. moist oral mucous membranes _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. Weight gain 6 lb (2.72 kg) over 5 days _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. Client states, “I need to sleep in my recliner at night.” Tachypnea, coarse lung crackles _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. 2+ radial pulses _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. apical pulse, 104, regular _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. bilateral lower leg edema _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. Client states, “I need to sleep in my recliner at night.” _______

How should a nurse assist a visually impaired patient to ambulate?

Which assessment is the greatest priority to report when considering the gastrointestinal (GI) changes that take place in the geriatric patient?

For each client finding choose whether or not the client achieved a positive or negative progress since admission. Weight loss of 3 lb (1.36 kg). A. positive B.  negative _______ For each client finding choose whether or not the client achieved a positive or negative progress since admission. Client states, “I slept with 3 pillows last night.” A.  positive  B.  negative _______ For each client finding choose whether or not the client achieved a positive or negative progress since admission. 1+ lower leg edema bilaterally A.  positive B.  negative _______ For each client finding choose whether or not the client achieved a positive or negative progress since admission. Client states, “I only need to read food labels when I am trying to reduce calories in my diet.” A.  postivie B.  negative _______ For each client finding choose whether or not the client achieved a positive or negative progress since admission. Client states, “I will use a pill organizer at home to keep up with my medications.” A.  positive B.  negative _______ For each client finding choose whether or not the client achieved a positive or negative progress since admission. Client has bronchovesicular lung sounds bilaterally A.  positive B.  negative _______

Which of the following is NOT a hypertonic fluid?

Order:  gentamycin 0.65 mg IM Stock:  vial of gentamycin 20 mg/2 mL How many mL will you administer (round to the nearest hundreth)

Chief Complaint:The patient reports feeling fatigued and experiencing frequent headaches for the past week. They also report generalized muscle weakness, which has worsened over the past few days. The patient notes that they have gained approximately 6 pounds (2.72 kg) over the last 5 days and states, “I need to sleep in my recliner at night because lying flat makes it hard to breathe.” Past Medical History: Hypertension Type 2 Diabetes Mellitus CHF Vital Signs at Admission: Blood Pressure: 120/80 Pulse: 104 bpm (apical, regular) Respiratory Rate: 24 breaths/min Temperature: 98 oral O2 Saturation: 95% RA The nurse recognizes the client is most likely experiencing (choose one and write the letter): A. atelectasis B.  fluid volume excess C. pneumothorax _______ as evidenced by (choose one and write the letter): A.  worsening dyspnea B.  muscle weakness C.  2+ radial pulses _______ and A.  capillary refill, less than 2 seconds B.  moist oral mucous membranes C.  weight gain _______

A patient is to receive ampicillin (Unasyn) IV piggyback in 100 mL of fluid every 8 hours. The main intravenous (IV) line of D5W is running at 50 mL/hr and is on time. A nurse’s responsibility is to calculate the total 24-hour intake. At the end of the 24-hour shift, how much IV intake should the nurse document that the patient has received?