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The nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes when auscultating a client's lungs. How should this finding be recorded? - Fine crackle... s are short, high pitched sounds heard just before the end of inspiration that are the result of rapid equalization of pressure when collapsed alveoli or terminal bronchioles suddenly snap open. The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding? - Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may result from oculomotor nerve or eyelid muscle disorder. A client's family asks why their mother with heart failure needs a pulmonary artery catheter now that she is in the ICU. What information should the nurse include in the explanation to the family? - Pulmonary artery catheters are used to measure central pressures and fluid balance. Even though all clients in the ICU require close monitoring, they do not all need a PA catheter Several hours after surgical repair of an abdominal aortic aneurysm, the client develops left flank pain. The nurse determines the client's urinary output is 20 mL/hr for the past 2 hours. - Postoperative complications of surgical repair of AAA are related to the location of resection, graft, or stent placement along the abdominal aorta. Embolization of a fragment of thrombus or plaque from the aorta into a renal artery can compromise blood flow in one of the renal arteries, resulting in renal ischemia that precipitates unilateral flank pain. The nurse should conclude that these findings support which complication? - Intraoperative blood loss or rupture of the aorta anastomosis can cause acute renal failure related to hypovolemia. The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency and stress incontinence. She also reports difficulty emptying her bladder. These complaints are most likely due to wh [Show More]

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