A laboring client has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, the nurse would expect to do which of the following?
A. Observe fetal heart rate variability.
B. Rapidly infuse 500-1000 ml of intravenous fluids.
C. Place the client in the semi-Fowler's position.
D. Teach the client appropriate breathing techniques.
B
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When monitoring the vital signs of a patient who has sustained a major burn injury, the nurse assesses a heart rate of 112. What should the nurse determine about this finding?
1. This heart rate is normal for the patient's post-burn injury condition. 2. The patient is demonstrating manifestations consistent with the onset of an infection. 3. The patient is demonstrating manifestations consistent with an electrolyte imbalance. 4. The patient is demonstrating manifestations consistent with renal failure.
The nurse understands that to prevent pressure ulcers, pressure must be removed from high-risk areas of the body
What nursing interventions are essential to accomplish this goal? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pull the patient up in bed every 2 hours or less. 2. Turn the patient at least every 2 hours. 3. Encourage the patient to be out of bed. 4. Position articles the patient uses just out of reach to encourage movement. 5. Float the heels off the bed with pillows beneath the ankles.
A nurse takes a tympanic temperature in a 2-year-old patient by pulling the pinna
1. Upward and back. 2. Upward and forward. 3. Downward and forward. 4. Downward and back.
Which intervention is most important for a person who is in a wheelchair for long periods?
a. Reposition self every 2 hours. b. Lift weight on the arms of the chair every 15 minutes. c. Massage bony prominences of the but-tocks and hips. d. Use a donut device to keep weight off of the buttocks.