A patient in the intensive care unit has been diagnosed with systemic inflammatory response syndrome (SIRS)
What additional findings indicate the patient is becoming septic? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Blood pressure 70/48 mm Hg
2. Urine output 10 mL/hr
3. Blood glucose level 185 mg/dL
4. Heart rate 88
5. Respiratory rate 16
1,2,3
Rationale 1: Hypotension is an indication of sepsis.
Rationale 2: Decreased urine output is an indication of sepsis.
Rationale 3: Plasma glucose greater than 120 mg/dL is an indication of sepsis.
Rationale 4: A heart of rate of 88 is within normal limits and does not indicate sepsis.
Rationale 5: A respiratory rate of 16 is within normal limits and does not indicate sepsis.
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Complete this analogy. NANDA : clinical judgment :: NIC : _________________
a. patient outcomes b. nursing actions c. diagnosis d. symptoms
Which of these phrases BEST describes learning?
a. absorbing facts and concepts b. sharing information with others c. behavior change resulting from assimilation of information d. acquisition of knowledge
The nurse must be sure to instruct the patient about which potential adverse effect(s) of tricyclic antidepressants? (Select all that apply.)
a. Diarrhea b. Dryness of mouth, nose, and throat c. Constipation d. Nocturia e. Urinary retention f. Blurred vision
The nurse is reinforcing teaching provided to a patient with pernicious anemia. Which patient statement indicates that teaching has been effective?
a. "I can miss a month or two of injections if I am feeling better." b. "I will need to take vitamin B12 injections for the rest of my life." c. "I will take the vitamin B12 injections until my strength returns." d. "I can take a vitamin B12 injection when I feel tired or fatigued."