The nurse receives report on an adult client with pneumonia. During report the nurse notes that the client has a new-onset heart block on the EKG (prior EKGs showed normal sinus rhythm) and has been running a temperature. Which vital sign is the most important to monitor for this client?
a. Blood pressure
b. Heart rate
c. Respirations
d. Temperature
b. Heart rate
rationale: A client who has a new-onset heart block must be monitored closely for bradycardia. They may require external pacing if they do not have a pacemaker, so monitoring this client's heart rate is the priority.
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Which finding would lead the nurse to suspect that a child is experiencing moderate dehydration?
A) Dusky extremities B) Tenting of skin C) Sunken fontanels D) Hypotension
The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized
The nurse irrigates the patient's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? A) Maintain the irrigation fluid at a warm temperature. B) Instill short, sharp bursts of fluid into the ear canal. C) Follow the procedure with insertion of a cerumen curette to extract missed ear wax. D) Have the patient stand during the procedure.
A patient is taking an FGA for schizophrenia. The nurse notes that the patient has trouble speaking and chewing and observes slow, wormlike movements of the patient's tongue. The nurse recognizes which adverse effect in this patient?
a. Acute dystonia b. Akathisia c. Parkinsonism d. Tardive dyskinesia
Hematemesis is best described as:
a. vomiting blood c. bloody diarrhea b. bleeding gastric ulcer d. black, sticky, tar-like stools