A client has been admitted from a nursing home for a workup to determine the cause of several recent falls. What intervention by the nurse takes priority?
a. Obtain a clean catch or catheterized urine specimen.
b. Document the number of and causative factors for falls.
c. Review the results of recent laboratory work for kidney function.
d. Facilitate neurologic and social work consultations.
A
Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often UTI symptoms in older adults are atypical, and a UTI may present with new onset of confusion or of falling.
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How will each of the errors affect a client's blood pressure reading?
A. Blood pressure cuff too narrow __________________________ B. Blood pressure cuff too wide ____________________________ C. Assessing immediately after smoking _____________________ D. Assessing immediately after eating _______________________ E. Assessing when the client is in mild-to-moderate pain __________ F. Assessing when the client experiences severe pain _________________ G. Assessing immediately after exercise ______________________
A postoperative patient is complaining of incisional pain. An order has been given for morphine every 4 to 6 hours PRN. The first assessment by the nurse should be to:
1. assess for the presence of bowel sounds. 2. assess pupillary reaction. 3. ask the patient's family if she is having pain. 4. see when the patient last received pain medication.
A 62-year-old man is to receive lidocaine as
treatment for a symptomatic dysrhythmia. Upon assessment, the nurse notes that he has a history of alcoholism and has late-stage liver failure. The nurse will expect which adjustments to his drug therapy? a. The dosage will be reduced by 50%. b. A diuretic will be added to the lidocaine. c. The lidocaine will be changed to an oral dosage form. d. An increased dosage of lidocaine will be prescribed so as to obtain adequate blood levels.
While caring for a client with severe aortic stenosis, the nurse understands that limited activity is essential to prevent fatigue. Which of the following instructions is (are) appropriate? Select all that apply
1. Discontinue activity if chest pain or shortness of breath occurs. 2. Explore sedentary activities. 3. Maintain balanced nutrition to ensure adequate caloric intake. 4. Administer humidified oxygen as prescribed. 5. Follow a progressive activity schedule that increases activity level by 10% each week.