A patient is in critical care recovering from a spinal cord injury. As part of shift report, the nurse is told that the patient's injury is between C1 and C4 and involves the entire cord. The patient is on a mechanical ventilator
What is the best nursing action to provide for patient safety?
A) Be sure all side rails are up at all times
B) Keep the bed in low position when unattended
C) Verify that a functioning bag-mask resuscitator is at the bedside
D) Place the call light in the patient's hand
C
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The nurse identifies the following assessment findings on a client with pre-eclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 11 on dipstick; and edema of the hands, ankles, and feet
On the next hourly assessment, which of the following new assessment findings would be an indication of worsening of the pre-eclampsia? 1. Blood pressure 158/104 2. Urinary output 20 mL/hour 3. Reflexes 21 4. Platelet count 150,000
Sleep disturbance in critically ill patients is defined as insufficient duration or stages of sleep that results in
a. less sleep that promotes recovery. b. discomfort and interferes with quality of life. c. adaptation of the environment to promote sleep. d. more sleep that promotes recovery.
What physiological process causes the severe pain of menstrual cramps?
a. Mechanical stimuli b. Thermal stimuli c. Prostaglandin activity d. Histamine activity
The nurse is assessing a client for complications associated with parenteral nutrition therapy. The nurse checks for crackles (rales) and weight gain to identify a(n):
1. fluid overload. 2. pneumothorax. 3. air embolism. 4. infection.