The nurse is preparing to reassess a client admitted for congestive heart failure. Which part of the interview should the nurse use to update the diagnostic cues of the client?
A. Initial.
B. Preinteraction.
C. Psychosocial.
D. Focused.
Answer: D
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A patient is administered amiodarone (Cordarone) intravenously. Which of the following assessments should the nurse consequently prioritize?
A) Assess urine output every 5 minutes. B) Assess blood pressure at least every 5 minutes. C) Assess for increased bronchovesicular lung sounds. D) Assess for muscle rigidity.
A client is admitted to the emergency department with toxic shock syndrome. Which action by the nurse is the most important?
a. Administer IV fluids to maintain fluid and electrolyte balance. b. Remove the tampon as the source of infection. c. Collect a blood specimen for culture and sensitivity. d. Transfuse the client to manage low blood count.
The nurse would determine that medication education for a client prescribed sildenafil (Viagra) was successful when the client states which of the following?
1. "Grapefruit juice will decrease the effects of sildenafil (Viagra). " 2. "Sildenafil (Viagra) should be taken with food.". 3. "I can take only one pill in a 24-hour period.". 4. "I can take sildenafil (Viagra) anywhere from one to six hours before sex.".
The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider?
a. The bowel sounds are hyperactive in all four quadrants. b. The patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg.