A person has vomited. Which will promote comfort?
a. Oral hygiene
b. Turning and repositioning
c. Semi-Fowler's position
d. Assisting with elimination
A
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A patient with a spinal cord injury at T3–T4 experiences a sudden increase in blood pressure (BP) and has cool, pale, gooseflesh skin on the lower extremities. What should the nurse do while awaiting physician orders? (Select all that apply.)
a. Monitor BP every 5 minutes. b. Place the patient in supine position. c. Check to see if the indwelling catheter is patent. d. Perform a rectal examination to determine if impaction is present. e. Place elastic stockings on the patient's legs.
The nurse caring for a 6-year-old child with acute glomerulonephritis anticipates that the most difficult part of the care will be implementing:
a. forced fluids. b. increased feedings. c. bed rest. d. frequent position changes.
As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply
A) INR above 1.0 B) Recent intracranial pathology C) Sudden symptom onset D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission
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