The nurse reviewing lab results notes that the C-reactive protein is elevated in the patient who had surgery 2 days ago. The nurse is aware this is an indication of:
a. impending infection.
b. possible hemorrhage.
c. a drug allergic reaction.
d. fluid deficit.
A
Since inflammation is an early response to infection, an elevation of the C-reactive protein (which elevates with inflammation) is an indicator of possible impending infection. C-reactive protein is not directly related to hemorrhage, drug reaction, or fluid deficit.
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A patient is considered terminal after being involved in a motor vehicle accident in which they received massive trauma to the head
As the patient's ICP increases and condition worsens, the family asks you what indications of approaching death will there be. What would be your best response? A) "There is a change in the pattern of their respirations." B) "Projectile vomiting and hemiplegia usually occur just before death." C) "Posturing may develop as pressure on the brainstem increases." D) "Loss of brainstem reflexes is a sign of approaching death."
The patient who has been on antidepressants for 3 days tearfully says, "I still feel rotten. I don't think anything can help how I feel." Which is the best response by the nurse?
a. "I will tell the charge nurse how you are feeling." b. "You will need to be patient and give your medicine some time to work." c. "Look how much you have improved since you were admitted to the facility." d. "It must be frustrating to be going through this difficult time."
The nurse demonstrates the proper technique for light palpation by which of the following?
A) Depressing the skin 1 to 2 centimeters with the dominant hand B) Feeling the surface structures using a circular motion C) Placing the nondominant hand on top of the dominant hand D) Using one hand to apply pressure and the other hand to feel the structure
Which of the following findings in a patient with decreased cardiac output would the nurse recognize as indicating that interventions are effective, and the patient is improving? (Select all that apply.)
a. Temperature 98.6°F (37°C), respirations 16/min, blood pressure 110/75 mm Hg, pulse 75 beats/min) b. Urine output greater than 30 mL/hour c. Cool pale extremities with diminished peripheral pulses d. Less shivering e. Clear lung sounds f. Pulse oximeter reading 96%