The triage nurse is taking vital signs of a 59-year-old African American male who has arrived to be treated for a laceration in his right hand. His blood pressure is 180/104
The nurse applies a dressing to his hand and plans for continuation of his care for the laceration. When questioning the client about his blood pressure, he states he did not know if that was normal for him and that he was not on any medication. In analyzing the blood pressure, the nurse decides
A) this is normal for someone in pain from an injury.
B) this finding is abnormal and presents an opportunity to initiate secondary prevention to prevent the progression of illness.
C) the blood pressure may not be accurate, therefore, it does not need to be addressed.
D) this patient needs to have his pressure taken in a standing position.
B
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A(An) ____________________ often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits
a. chemical burn b. electrical burn c. heat burn d. infection
The nurse would plan for a totally dependent client's safety by monitoring the client:
1. every hour. 2. every 2 hours. 3. every 4 hours. 4. once each shift.
The nurse understands that under normal circumstances digoxin exerts which of the following effects?
a. ? chronotropic; ? dromotropic; ? inotropic b. ? chronotropic; ? dromotropic; ? inotropic c. ? chronotropic; ? dromotropic; ? inotropic d. ? chronotropic; ? dromotropic; ? inotropic
A patient fell while walking in the hall. The medical orders include ambulate ad lib. The nurse
assigned to the patient had instructed the UAP to assist the patient when walking on an as needed basis. Earlier that morning the patient had informed the nurse and UAP that she was feeling weaker than usual. Who is legally liable for this patient's fall? A) The nurse since she was assigned to care for the patient B) The physician who wrote the order for the patient to ambulate ad lib C) Both the nurse and the UAP who had responsibility for the care of this patient D) The UAP since she was instructed to assist the patient when walking on an as needed basis