Which patient is at greatest risk for injury and requires the nurse's immediate attention? The patient who had a(n)
a. paracentesis 20 minutes ago and is sitting in bed with the arms resting on the overbed tray.
b. surgical repair of an incarcerated hernia yesterday and now has slight bruising at the incision site.
c. echocardiogram that showed an ejection fraction of 40% and has a resting heart rate of 110 occasional PVCs.
d. needle liver biopsy 1 hour ago and is now thrashing about in bed and complaining of severe abdominal pain.
ANS: D
You might also like to view...
While reading a research report, the nurse discovers that the researcher used a study instrument that has an established correlation coefficient of .54. How should the reader interpret this information?
1. This information is not pertinent to the critique of the study. 2. This instrument is not very reliable. 3. This is a very valid instrument. 4. The instrument is very reliable.
A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness
The nurse's rapid assessment reveals that the patient's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? A) Administer a Fleet enema as ordered and remain with the patient. B) Contact the primary care provider promptly and report these signs of perforation. C) Position the patient supine and insert an NG tube. D) Page the primary care provider and report that the patient may be obstructed.
Novolin R 22 units is to be administered. Which of the following syringes would be your preference?
A. tuberculin syringe B. standard 3 mL syringe C. 50 unit capacity U-100 syringe D. 100 capacity U-100 syringe
A patient with a sleep disorder reports taking valerian to sleep at night. For which adverse effect should the nurse assess the patient? (Select all that apply.)
1. Headache 2. Dizziness 3. Renal toxicity 4. Hepatotoxicity 5. Gastrointestinal disturbances