NURS 1503U Study Guide - Final Guide: Urinary Incontinence, Femoral Artery, Ileocecal Valve
Document Summary
Iv therapy including iv drug math - blood administration and tpn. Tachycardia is consistent with an infectious process. Abc (airway, breathing, circulation) priority: after obtaining vital signs, auscultate breath sounds (highest priority when pt. is showing respiratory distress). High temperature (fever) and rapid rr are vital sign findings of a problem, such as an infection. Jugular vein distension gives information about fluid volume overload. Because of pt"s fever, warm skin, and inelastic skin tugor, pt. more likely experiencing fluid volume deficit. Increased anterioposterior (ap) diameter of the chest is a finding typical in clients with emphysema, but is not an indicator of pneumonia. Clubbing of the fingernails is an indicator of chronic lung disease, such as chronic asthma or emphysema, but is not an indicator of acute infectious process such as pneumonia. Nurse auscultates crackles bilaterally in lower posterior lung fields with diminished breath sounds noted throughout all lung fields.