A postoperative nurse is caring for a patient following a tonsillectomy. The nurse notes the patient's blood pressure has decreased slightly. The patient is restless and the pulse rate is 116. The nurse should:
A) Medicate the patient for pain.
B) Place the patient in high-Fowler's position.
C) Increase the rate of the IV fluids.
D) Assess the patient for bleeding.
Ans: D
Feedback: The nurse would need to assess the patient for pain prior to providing the patient with pain medication. The patient should have the head of the bed elevated 30 degrees to prevent aspiration. The nurse would require a physician's order to increase the rate of the IV fluids. The nurse's primary responsibility based on the decreasing blood pressure and increasing pulse and restlessness would be to assess for hemorrhage.
You might also like to view...
In using verbal responses to assist the patient's narrative, some responses focus on the patient's frame of reference and some focus on the health care provider's perspective
An example of a verbal response that focuses on the health care provider's perspective would be: a. Empathy. b. Reflection. c. Facilitation. d. Confrontation.
The clinical nurse educator is teaching a group of nursing students about conducting a focused interview on a client being admitted to the facility with complaints of leg pain
Which statement by the student nurse indicates the need for further education? 1. "The focused interview will be guided by the physical assessment that was completed by the healthcare provider prior to admission." 2. "Subjective information is contained in the focused assessment." 3. "The age, gender, and past medical history of the client are used to guide the questions in the focused assessment." 4. "A focus interview on the musculoskeletal system is individualized for each client."
When doing adult CPR, compress the sternum straight down
A. 1/2 to 1 inch. B. 1 to 1.5 inches. C. 1.5 to 2 inches. D. 2.5 to 3.5 inches.
During the admission assessment of an individual admitted to the medical respiratory unit, the nurse notes the patient has a barrel-shaped chest. Which of the following assessments should the nurse perform next?
a. Assess the patient's rate and character of respirations b. Palpate the patient's thorax to determine presence of tenderness c. Obtain a blood sample for arterial blood gas (ABG) to detect respiratory acidosis d. Ask the patient about presence of a productive cough