When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. What is this pulse interpreted as by the nurse?
a. Normal
b. Bradycardic
c. Arrhythmic
d. Tachycardic
ANS: D
If the pulse is faster than 100 bpm on an adult patient, it is considered to be tachycardic.
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At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?
A. Immediately following the injury B. During the fluid shift C. During fluid remobilization D. During the late acute phase
A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful?
a. Teach the patient to fully exhale into the incentive spirometer. b. Administer ordered analgesic medications before these activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.
A pregnant woman diagnosed with anemia says, "I don't see how I could be anemic. I have been very careful to take iron tablets and to eat a balanced diet." The nurse's most appropriate response is:
a. "Have you had any bleeding that might have caused this?" b. "It is normal to be anemic during pregnancy, so don't worry about it." c. "During pregnancy, the fluid portion of your blood increases, which dilutes your red blood cells." d. "You need additional red blood cells to supply your baby's oxygen needs. Too many of your blood cells are going to your baby."
Daria is admitted to the medical-surgical unit experiencing an anxiety episode. Nurses on the unit are aware of several nursing interventions that can reduce the anxiety that Daria is experiencing (select all that apply):
A. Attempt to calm the patient by placing an arm around the person. B. Maintain a calm environment. C. Promote open communication. D. Provide the client with a safe, quiet, and private place. E. Document the patient's behavior.