A client who was involved in a motor vehicle accident is admitted through the emergency department. He has an IV of 0.9% NS @ 100 mL/hr, BP 92/58, and complains of weakness, fatigue, and abdominal pain
On assessment, the nurse discovers that Mr. Reynolds is nauseated and just vomited 560 milliliters of green emesis with flecks of "coffee grounds." The nurse delegates client care activities to the nursing assistive personnel. Which activity should the nurse keep?
A. Taking and recording vital signs every 15 minutes
B. Recording accurate intake and output
C. Obtaining a baseline weight to guide therapy
D. Increasing the IV rate to 250 mL/hr if the blood pressure drops to 85/50
ANS: D
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The nurse institutes measure to protect the preterm newborn from cold stress because:
A) it increases glucose utilization and contributes to the hypoglycemic state B) shivering consumes too many calories C) a low temperature may make the newborn less able to absorb nutrients D) cold decreases circulation to the extremities and the head, especially the brain
A young female client is experiencing manifestations of a UTI. Which question should the nurse ask to provide information that might help to prevent future UTI infections?
1. "Are you pregnant?" 2. "What kind of bath soap do you use?" 3. "How long have you been married?" 4. "Do you urinate after having sexual intercourse?"
A patient with type 1 diabetes is eating breakfast at 0730. Blood sugars are on a sliding scale and are ordered AC and HS
The patient's blood sugar level is 317. Which of the following formulations of insulin should the nurse prepare to administer? a. No insulin should be administered. b. NPH c. 70/30 mix d. Regular
When assigning the suicidal patient to a room on the unit, the nurse should select a:
a. Single room near the exit b. Double room near the exit c. Single room near the nurse's station d. Double room near the nurse's station