A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?
A) Position the head of the bed (HOB) flat.
B) Withhold intravenous fluids.
C) Administer a bolus of IV fluids.
D) Give an antihypertensive medications.
Answer: D) Give an antihypertensive medications.
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A patient has an infectious/inflammatory process of the eyelid. The primary goal of nursing intervention is
a. administering antibiotics. b. flushing the eye with sterile ophthalmic solution. c. maintaining bed rest. d. preventing further infection.
A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?
a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is ex-pected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.
Which of the following nursing actions is appropriate in the care of a patient with an implanted vascular access device?
A) Cleanse around the site of insertion with an antibacterial solution B) Clean the external portion of the catheter after infusion is complete C) Maintain patency by routine flushing with a heparinized solution D) Observe the site only; only the physician will assess the site
A 39-year-old diabetic patient is at the clinic having a foot check done by the nurse
The nurse notes that the patient's right foot is pale and mottled, cool to touch, with a capillary refill of > 3 seconds. What would the nurse suspect the patient has? A) Hematogenous osteomyelitis B) Osteomyelitis with vascular insufficiency C) Contiguous-focus osteomyelitis D) Osteomyelitis with muscular deterioration