A nurse is caring for a patient with a kidney infection. Output is tallied at the end of the shift, and the nurse notes that the patient has voided 240 mL in the past 8 hours. Next, the nurse should
1. Notify the physician.
2. Document the amount as normal output.
3. Take the patient's temperature.
4. Evaluate the patient's blood pressure.
ANS: 2
You might also like to view...
The risk of aspiration while on mechanical ventilation can be reduced by
A) leaving the endotracheal tube's cuff deflated. B) administering enteral feedings. C) inserting a nasogastric tube. D) administering prophylactic antacids.
A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position?
A) Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray. B) Turn the patient to enable assessment of all the patient's lung fields. C) Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall. D) Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds.
A client with an aortic aneurysm is about to undergo surgery for repair of the aorta. Prior to surgery, the nurse should instruct the client to:
1. Hold her breath when defecating. 2. Keep her legs flat when in bed. 3. Report a headache to the nurse. 4. Continue taking anticoagulants.
The nurse working with older patients understands what fact about a health care proxy?
a. It states that no resuscitation should occur if breathing or heartbeat cease. b. It can specify what treatment measures are or are not acceptable to the patient. c. It explains patient's wishes regarding treatment if the patient cannot communi-cate. d. It designates a surrogate health care deci-sion maker if the patient is incapacitated.