The nurse is planning interventions for a trauma patient to prevent the onset of the lethal triad
What will the nurse include in this patient's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Monitor temperature.
2. Measure intake and output.
3. Evaluate laboratory data.
4. Assess arterial blood gas values.
5. Measure gastric pH.
1,2,3,4
Rationale 1: Monitoring body temperature is critical in the prevention of deaths from the lethal triad.
Rationale 2: Measuring intake and output is critical in the prevention of deaths from the lethal triad.
Rationale 3: Evaluating recent laboratory data is critical in the prevention of deaths from the lethal triad.
Rationale 4: Assessing arterial blood gas values is critical in the prevention of deaths from the lethal triad.
Rationale 5: Measuring gastric pH is not critical in the prevention of deaths from the lethal triad.
You might also like to view...
A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look."
Which response would be most consistent with anorexia nervosa? a. "I'm fat and ugly.". b. "What I think about myself is my business.". c. "I'm grossly underweight, but I cover it well.". d. "I'm a few pounds overweight, but I can live with it.".
A nursing instructor asks a group of students, "What are some of the complications from male genital piercings?" Which responses by the students would indicate that further study is necessary? Select all that apply
a. Bleeding d. Paraphimosis b. Hypertension e. Urethral tears c. Hypersensitivity f. Urinary incontinence
A person who is receiving tests to confirm a diagnosis of Alzheimer's disease is preparing for a computerized tomography (CT) test. The patient becomes restless and is unable to follow the pre-examination directions given by the lab personnel
As the nurse who is assisting the patient, your best action at this time is: A) Tell the patient that refusing to cooperate will require having to return another day B) Give the patient the written instructions C) Take the patient to a quiet waiting area until it is time for the CT scan D) Make certain that the patient is tightly strapped to the examination table during the test
The nurse notes that a pregnant patient's maternal serum alpha-fetoprotein (MSAFP) levels are elevated. What does this information suggest to the nurse?
A) Her child is at risk for Down syndrome B) Her child is at risk for neural tube defects C) The test may have been run during the wrong weeks' gestation D) Further tests are required based on the results