Which of the following should the nurse include when planning intrapartum care for a client with heart disease?
a. Take vital signs according to standard protocols.
b. Continuously monitor cardiac rhythm with telemetry.
c. Massage the uterus to hasten delivery of the placenta.
d. Maintain infusion of intravenous fluids to avoid dehydration.
B
A client with heart disease should have a cardiac monitor and possibly an arterial line for continuous blood pressure monitoring as well as hemodynamic monitoring.
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The nurse is reviewing the plan of care for a client who was admitted for suicidal tendencies. The nurse documents that the client is no longer experiencing thoughts of hurting self. Which step of the nursing process is the nurse using?
1. Implementation. 2. Evaluation. 3. Planning. 4. Assessment.
A client expresses concern that her 3-hour-old newborn is difficult to awaken. The nurse explains that this behavior indicates:
A) normal progression into sleep cycle C) a physiological abnormality B) probable hypoglycemia D) poor oxygen saturation and perfusion
Each of the following factors may contribute to a diagnosis of acute confusion EXCEPT:
1. disrupted circadian rhythm. 2. infection. 3. apraxia. 4. electrolyte imbalance.
The nurse has identified a priority problem on her unit. Which statement is true regarding addressing a priority problem?
A) Setting priorities involves skipping interventions. B) Priorities are set at predetermined intervals throughout the shift. C) A priority problem requires a nursing intervention before another problem is addressed. D) Priority of problems is established and continued according to the nursing plan of care. E) The physician is responsible for determining priority of client needs.