The nurse is assessing a client who has septic shock. The following assessment data were collected: Baseline Data Today's Data Heart rate 75 beats/min 98 beats/min Blood pressure 125/65 mm Hg 128/75 mm Hg Respiratory rate 12 breaths/min 18
breaths/min Urinary output 40 mL/hr 40 mL/hr The nurse correlates these findings with which stage of shock? a. Early
b. Compensatory
c. Intermediate
d. Refractory
A
An increase in heart and respiratory rates (heart rate first) from the client's baseline and a slight increase in diastolic blood pressure may be the only objective manifestations of early shock. These findings do not correlate with other stages of shock.
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Which finding on a health history would lead the nurse to suspect that a client has an increased risk for sexually transmitted infections (STIs)?
A) Rash and fever for two days C) Weight gain of 10 pounds B) Five different sexual partners D) White vaginal discharge
What does the actual analysis of data usually begin with?
A) A search for major themes B) Entering information into files C) The use of quasi-statistics D) Developing a system for organizing and indexing the data
The nurse is assessing a female patient who has been taking chlorpromazine for schizophrenia. What should the nurse include in this assessment?
1. Perform an eye exam and ask if there have been changes in vision. 2. Draw blood to check a lipid profile. 3. Ask the patient questions regarding amount of alcohol intake. 4. Determine the date of her last menstrual period. 5. Draw blood to check thyroid function.
The nurse has just collected blood by venipuncture in the antecubital fossa. Which should the nurse do next?
a. Keep arm extended while applying a bandage to the site. b. Keep arm extended, and apply pressure to the site for a few minutes. c. Apply a bandage to the site, and keep the arm flexed for 10 minutes. d. Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several minutes.