The nurse plans a safety program for the patients on a medical-surgical unit. Which patient has the greatest likelihood of falling?
a. A 79-year-old after a pacemaker battery replacement
b. A 68-year-old anemic who is dehydrated and has heart failure
c. A 21-year-old fresh postarthroscopy after a college football injury
d. A 33-year-old post–right salpingectomy for ectopic pregnancy
B
The patient with anemia and dehydration with heart failure has the highest risk of falling. The patient will be taking other medications, including antihypertensive agents that increase the risk of falls caused by confusion, dizziness, or orthostatic hypotension. The replacement of a pace-maker battery in a stable patient is a low-risk, routine procedure. The 21-year-old recovering from the arthroscopy is most likely a healthy adult who is stable while ambulating. The 33-year-old postsalpingectomy is most likely to be healthy but may be a little hypotensive if much bleeding occurred before surgery.
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A major flood has occurred in the community. The nurse is preparing to assist the community, and is aware that a priority is to:
1. Help prevent the spread of infection. 2. Ensure that all ordered laboratory studies are completed. 3. Provide food for the victims. 4. Provide appropriate shelter for victims.
A patient is suspected of having severe sepsis. What should the nurse anticipate concerning antibiotic therapy for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Several antibiotics will be started on the same day. 2. The antibiotic prescribed will be one commonly used in the hospital. 3. The initial antibiotic will be broad-spectrum. 4. The antibiotic therapy will be reevaluated in 2 or 3 days and is likely to be changed. 5. Before choosing an antibiotic, the prescriber will ask questions about where the patient lives and has traveled.
During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect?
A) Gouty arthritis B) Rheumatoid arthritis C) Degenerative joint disease D) Plantar fasciitis
The nurse is preparing a patient who will be having a digital retinal scan. Which patient statement indicates further teaching is necessary?
a. "This test is used to help detect eye disease early." b. "The scanner will take a picture in about 2 seconds." c. "My eyes will need to be dilated before the procedure." d. "A digital image of most of my retina will be produced for the doctor to view."