The nurse is providing care to a patient who is receiving a blood transfusion and who becomes acutely short of breath and anxious within a few minutes of the nurse's initiating the transfusion
Which of the following actions will be included in the nurse's care? Select all that apply.
1. Frequent checks of the vital signs
2. Stopping the blood transfusion and notifying the physician
3. Sending tubing and unused blood to the blood bank
4. Obtaining a urine sample for analysis
5. Discontinuing the intravenous (IV) site
ANS: 1, 2, 3, 4
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3 1/2 fluid oz = _____ mL
a. 105 b. 52.5 c. 28 d. 150
During a therapy session a client cries as the nurse explores the relationship of the client and her
now-deceased mother. The client sobs "I shouldn't be blubbering like this.". A response by the nurse that will hinder communication is a. "The relationship with your mother is very painful for you.". b. "I can see that you feel sad about this situation.". c. "Why do you think you are so upset?" d. "Crying is a way of expressing the hurt you're experiencing.".
The client is perspiring, has an increase in pulse and blood pressure, and states, "I am so worried about this operation I can't think straight." What is the most appropriate nursing diagnosis for this client?
a. Ineffective individual coping b. Anxiety c. Powerlessness d. Impaired adjustment
After a long-term care facility nurse receives a phone order from the physician, the nurse must ensure that the order is countersigned in
a. 8 hours. b. 12 hours. c. 24 hours. d. 48 hours.