The nurse is caring for a client who is ordered Hyperstat IV to decrease blood pressure. Which nursing consideration is a priority?
A) Elevate the head of the bed.
B) Use an automatic blood pressure recording machine.
C) Place a Foley catheter to monitor urine output.
D) Assess the client's deep tendon reflex.
B
Feedback:
A nursing priority is to monitor the client's blood pressure every few minutes. It is unrealistic to have the nurse manually assess the blood pressures. An automatic blood pressure machine is programed to assess the blood pressure and record the results for assessment. The other options may be completed; however, monitoring the blood pressure is the priority.
You might also like to view...
A nurse working with a couple in the infertility clinic notes the diagnosis of cryptorchidism on the man's chart. What assessment question by the nurse is most important?
A. "Did you have surgery for your undescended testes?" B. "Do you have a family history of testicular cancer?" C. "Do you use lead shielding when you get x-rays?" D. "For how long did you undergo chemotherapy?"
An elderly client diagnosed with Type 2 diabetes mellitus frequently reports that his tea is "way too sweet" even though the staff adds only the 1 teaspoon of sugar substitute the client requests
The most likely reason for this response is that: 1. The client's perception of sweetness has become more sensitive. 2. Sugar substitutes are sweeter than natural sugar. 3. Diabetes mellitus can alter one's tolerance for sugar. 4. The client has not adjusted to the use of sugar substitutes.
Suicide risk is highest among clients who have been diagnosed with which of the following?
A) Borderline personality disorder B) Paranoid personality disorder C) Schizoid personality disorder D) Obsessive–compulsive personality disorder
A 16-year-old patient on a pediatric unit who underwent an appendectomy for a ruptured appendix 3 days ago complains of acute pain and has a high fever
The nurse is concerned that she may have an infection and notifies the health care provider of the change in her condition. This concern is based on the nurse's experience as a pediatric nurse. Her ability to make a tentative conclusion regarding this patient's situation based on observed data is known as what? A. Scientific method B. Clinical inference C. Effective problem solving D. Data collection