The patient's pulse is below 60. The nurse is aware that the patient is not receiving digoxin. What does the nurse suspect is causing the bradycardia?
a. Low exercise tolerance
b. Unrelieved severe pain
c. Excessive bed rest
d. A prone position
ANS: B
Bradycardia can result from unrelieved severe pain.
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The nurse is caring for a mechanically intubated patient with a history of developing pneumonia when intubated. Which of the following should the nurse do to prevent the onset of pneumonia for this patient?
1. Increase intravenous fluids. 2. Suction only when necessary. 3. Provide prophylactic medication to prevent stress ulcer formation. 4. Keep head of bed elevated and provide oral care.
The nurse is caring for a patient diagnosed with cardiogenic shock due to cardiomyopathy. Which of the following manifestations is the nurse most likely to assess in this patient?
1. wheezing 2. S3 or S4 heart sound 3. pericardial friction rub 4. personality changes
Nursing notes should primarily be:
a. objective, as data should reflect what theindividual has said b. objective, as data should reflect what is observed. c. subjective, as data should reflect what is observed. d. subjective, as data should be made without making assumptions.
The nurse is teaching incisional care to a patient who has been discharged after abdominal surgery. Which priority instruction must the nurse include?
a. Do not rub or touch the incision site b. Practice proper hand washing c. Clean the incision site two times a day with soap and water d. Splint the incisional site as often as needed for comfort