What is the nurse's first priority when a patient receiving IV fluid therapy shows an increase in blood pressure and has bilateral crackles?
a. Raise the head of the bed
b. Slow the infusion
c. Turn the patient to the left side
d. Notify the charge nurse
ANS: B
When signs of circulatory overload are observed, the infusion is slowed down initially, then the nurse should notify the charge nurse.
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A patient who has a permanent pacemaker must have surgery to repair a bowel obstruction. Which information should the nurse provide this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. "Because the surgical area is in your abdomen, the fact that you have a pacemaker is not important.". 2. "Some changes in medication given during the surgery will be necessary.". 3. "Your surgeon will need information about the type of pacemaker.". 4. "Your pacemaker will have to be turned off before surgery.". 5. "Cardiac monitoring during surgery will be different because you have a pacemaker.".
A nurse in a community health center has been having regular meetings with a woman who wants to stop smoking. Which of the following outcome decision options would the nurse document if the woman has not smoked for 3 months?
A) outcome met C) outcome not met B) outcome partially met D) outcome inappropriate
A nurse counselor has been using Aguilera's crisis theory as the approach to a young woman who was raped. The nurse counselor would expect which of the following client behaviors during the resolution phase?
a. deteriorates in coping mechanisms and become anxious and depressed b. does not want to talk about the rape to anyone while hiding fear and anxiety c. continues to use previous coping strategies to deal with an attempt to reduce stress d. begins to make realistic plans for the future and discusses the ways in which the present experience may help with coping with future crises
The person living at the nursing center is to be bathed this evening. The person is not allowed to shower and is totally dependent. How will you provide a complete bed bath? How will you ensure privacy during this process?
What will be an ideal response?