A client is recovering after a coronary catheterization. What assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)
a. Blood pressure of 140/88 mm Hg
b. Serum potassium of 2.9 mEq/L
c. Warmth and redness at the site
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor
B, D, E
In the first few postprocedure hours, the nurse monitors for complications, such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dys-rhythmias. The client's blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours.
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The nurse is providing home care for a 1-year-old girl who is technologically dependent. Which intervention will best support the family process?
A) Finding an integrated health program for the family B) Teaching modifications of the medical regimen for vacation C) Assessing family expectations for the special-needs child D) Creating schedules for therapies and interventions
A client is recovering from a gastrojejunostomy for treatment of duodenal ulcer. About 20 minutes after lunch, the client develops dizziness, weakness, palpitations, and the urge to defecate
To avoid recurrence of these symptoms, what should the nurse teach the client? 1. Decrease fluid intake with meals and lie down after meals. 2. Drink fruit juice after each meal. 3. Increase fluid intake with meals and lie down 30 minutes after meals. 4. Eat a high-carbohydrate, low-fat diet in six small feedings a day.
During the physical examination of a client, the nurse should monitor for signs that may indicate a urinary tract disorder. Which of the following signs indicates that the client may have a urinary tract disorder?
A) Lightheadedness B) Malaise C) Periorbital edema D) Flank pain
The nurse is teaching a class on immunosuppressants to a group of nurses to review their current knowledge
The nurse asks, "Which patient is likely to receive Rho(D) immune globulin RhIG (RhoGAM)?" The group correctly gives which of the following answers? a. A pregnant patient who is Rho negative b. A renal transplant patient who is Rho positive c. A bone marrow transplant patient who is Rho negative d. A heart transplant patient who is Rho positive