Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which of the following would the nurse expect to assess? (Select all that apply.)
A) Diaphoresis
B) Tachycardia
C) Oliguria
D) Cool extremities
E) Confusion
A, D
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The nurse is performing an assessment of the client's peripheral vascular system. Which actions by the nurse are appropriate when assessing this client?
1. Assessing the client in a flat, supine position when the client exhibits a respiratory rate of 26 breaths/min. with a dusky appearance around the mouth and lips. 2. Requesting the client remove all undergarments prior to putting the gown. 3. Assessing pedal pulses over the client's socks. 4. Taking a blood pressure cuff, Doppler, and stethoscope into the client's room for the assessment.
An LPN/LVN finds a young man tearfully staring out the window. He says, "I've been in this hospital 23 days out of the last 50 . I've lost a lot of pay." What response by the nurse should be used to encourage further communication?
a. "You've lost a lot of work?" b. "Would you like me to arrange an ap-pointment for you to speak with the social worker?" c. "How much pay have you lost?" d. "You are to be discharged at the end of the week, and you can return to work."
A client has a heart rate of 130 beats per minute. How does the nurse plan to document this heart rate in the medical record?
1. Atrial fibrillation. 2. Bradycardia. 3. Tachycardia. 4. Premature ventricular contraction.
The nurse is assessing a client for taking self-responsibility in wellness. Which action by the client should the nurse consider reflects good decision making?
A. Planning a menu that includes a variety of foods. B. Decreasing the number of cigarettes smoked from 3 packs per day to 1.5 packs per day. C. Walking at a pace of 3 to 4.5 mph for 15 minutes three times per week. D. Practicing sexual abstinence or using a condom during sexual intercourse.