A 77-year-old woman with a diagnosis of congestive heart failure has experienced a downward trend in her hemoglobin levels in recent days, and her care team ordered the administration of two units of packed red blood cells
In the hours following her blood transfusion, the patient complained of increasing shortness of breath, and chest auscultation revealed diffuse crackles. The nurse also noted an increase in the patient's peripheral edema, and fluid volume excess (FVE) is suspected. What assessment should the nurse prioritize in the care of this patient?
A) Close monitoring of the patient's intake and output
B) Assessment of the patient's hemoglobin, hematocrit, and red blood cell levels
C) Neurovital signs q1h
D) Assessment of the patient's electrolyte levels
A
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While being comforted in the Emergency Department, the 7-year-old sibling of a pediatric trauma victim blurts out to the nurse, "It's all my fault! When we were fighting yesterday, I told him I wished he was dead!" The nurse, realizing that the
child is experiencing magical thinking, should respond by: 1. Asking the child if he would like to sit down and drink some water. 2. Sitting the child down in an empty room with markers and paper so that he can draw a picture. 3. Calmly discussing the catheters, tubes, and equipment that the patient requires, and explaining to the sibling why the patient needs them. 4. Reassuring the child that it is normal to get angry and say things that we do not mean, but that we have no control over whether an accident happens.
A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery
What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.
Compare the following drugs, and select the one that would lead the health care provider to carefully assess the patient for opisthotonos during emergence from anesthesia
a. Propofol (Diprivan) b. Sodium pentothal (Pentothal) c. Etomidate (Amidate) d. Ketamine (Ketalar)
When washing a patient's eyes,
A. use liquid soap and wash from inner corner to outer corner. B. use bar soap and wash from outer corner to inner corner. C. never use soap and wash from inner corner to outer corner. D. never use soap and rub back and forth.