The nurse is caring for a patient who suddenly begins having large amounts of bright red hematemesis. After the patient is turned onto the side, what should the nurse do?
a. Obtain the patient's vital signs.
b. Encourage iced oral fluids.
c. Lower the head of the bed.
d. Place a cool cloth on the patient's forehead.
ANS: A
Collect data including vital signs to report to RN and physician for treatment orders.
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Which question does the nurse ask the client who has isotonic dehydration to determine a possible cause?
a. "Do you take diuretics, or ‘water pills'?" b. "What do you normally eat over a day's time?" c. "How many bowel movements do you have daily?" d. "Have you been diagnosed with diabetes mellitus?"
According to the Nursing Intervention Classification system, Domain 6 generally deals with issues related to
a. basic physiological needs c. health systems b. complex physiologi-cal needs d. behavioral issues
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations?
a. Proceed to the next patient's room to make rounds. b. Determine the patient does not want any pain medicine. c. Ask the patient about the facial grimacing with movement. d. Administer the pain medication ordered for moderate to severe pain.
Which of the following teenagers is exhibiting a behavior that cause for concern and requires further evaluation?
a. Is always very happy b. Is agitated and has trouble sleeping c. Has a lot of homework and stays up late to finish it d. Values his friends opinion more than his parents opinion