The nurse is caring for a patient with gastroenteritis who has been vomiting for 48 hours. A family member of the patient asks the nurse,
"Why is he breathing that way?" What is the nurse's most accurate response after explaining the meaning of pH? "He is breathing
a. Fast and deep to help reduce carbon dioxide to increase his pH"
b. Slow and shallow to try to retain carbon dioxide to decrease his pH"
c. Fast and deep to help reduce carbon dioxide to decrease his pH"
d. Slow and shallow to try to retain carbon dioxide to increase his pH"
ANS: B
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A nurse is planning care for a 59-year-old woman who is on ranitidine therapy. The nurse is concerned for the patient's safety. Which of the following would be an appropriate nursing diagnosis?
A) Diarrhea related to adverse effects of drug therapy B) Acute Pain related to adverse drug effects, headache C) Risk for Injury related to drug-induced somnolence, dizziness, confusion, or hallucinations D) Potential Complication: Electrolyte Imbalance related to hypophosphatemia, secondary to drug therapy
After reviewing a client's history, which factor would the nurse identify as placing her at risk for gestational hypertension?
A) Mother had gestational hypertension during pregnancy. B) Client has a twin sister. C) Sister-in-law had gestational hypertension. D) This is the client's second pregnancy.
A patient is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period?
A) Encourage to continue breastfeeding. B) Suggest breastfeeding be discontinued. C) Instruct on supplementing feedings with formula. D) Explain how breastfeeding will weaken the patient's condition.
The nurse is caring for a patient recovering from surgery. Which intervention will provide the most pain relief for the patient?
1. Offer pain relief before the patient complains of pain. 2. Wait until the patient can describe the pain specifically. 3. Assess the pain level every 4 hours around the clock. 4. Allow the patient to "sleep off" the anesthesia, then offer pain medication.