An aide tells the nurse that an older adult patient has a pulse of 105 beats/min. This pulse rate should be taken seriously because of what?
A) Older adults have poor cardiac reserves
B) The patient is likely taking many medications
C) The patient needs to be reassured that providers care
D) Older adults usually have lower than normal pulse rates
A
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The nurse is caring for a client diagnosed with pneumonia who was placed on a cardiorespiratory monitor. Vital signs are recorded from the monitor in order to allow the client to remain undisturbed during the night
The nurse observes that the blood pressure, heart rate, and respirations are 20% below baseline. The nurse concludes which of the following? 1. The client is about to have a cardiac arrest. 2. The client is in stage 2 of NREM sleep. 3. The client's metabolic rate has increased. 4. The client is in stage 4 of NREM sleep.
A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include:
a. aloofness, increased distractibility, and suspicion. b. elevated mood, hypertalkativeness, and distractibility. c. performing rituals and avoiding open places. d. darting eyes, distracted, and mumbling to self.
A patient asks the nurse, "What is blood pressure?" The nurse would most appropriately respond:
1. "A measurement that should always be 120/80 unless complications are present." 2. "The amount of pressure exerted on your veins by the blood." 3. "A measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against." 4. "A complex measurement that should only be discussed with your health care provider."
A nurse is preparing to administer ferrous sulfate IM to a client with anemia. What should the nurse consider when giving this injection?
1. Give the injection in the deltoid muscle. 2. Iron is best absorbed if given subcutaneously. 3. Iron is irritating to the tissues. 4. The z-track method should be used. 5. Iron preparations should be administered through a needle gauge 16 or larger.