Which action should the nurse take first?
A. hold Raymond's breakfast tray to provide bowel rest.
B. perform oral care and moisten mucous membranes
C. take Raymond's BP to assess for postural hypotension
D. notify HCP of Raymond's weak, rapid pulse
Answer: C. take Raymond's BP to assess for postural hypotension
You might also like to view...
A 75-year-old male client is brought to the clinic by his son. The son states, "Ever since Mom died, Dad hasn't been the same. At first he just seemed sad, but now he seems to get mixed up about everything
" The nurse is aware that based on the client's history, the source of confusion is most likely: a. Dementia b. Depression from the loss of his wife c. Hypoxia of the brain d. Delirium from medications
The nurse is planning care for a client with erectile dysfunction. What should the nurse include in this client's plan of care?
Select all that apply. A) Names of psychologists with experience in treating the disorder B) Information on medications for treatment C) Types of devices and surgeries available to help with the disorder D) Reason for disorder as being side effect of prescribed medication E) Information on exact cause
The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate?
a. Insert an oral airway to prevent aspiration and to protect the airway. b. Offer the patient an emesis basin so that you can measure the amount of emesis. c. Prepare to suction the oropharynx while maintaining cervical spine immobilization. d. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.
You are admitting a patient who has presented to the emergency room with dilated cardiomyopathy (DCM). What changes in the heart characterize DCM?
A) Dilated ventricles with atrophy of the ventricles B) Dilated ventricles without hypertrophy of the ventricles C) Hypertrophy of the ventricles with no dilation of the ventricles D) Dilation of the atria and hypertrophy of the ventricles