What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well?
a. Recheck the infant's blood pressure.
b. Alert the physician.
c. Withhold oral feeding.
d. Increase the oxygen rate.
B
Feedback
A Although this may be indicated, it is not the priority action.
B These are signs of early congestive heart failure, and the physician should be
notified.
C Withholding the infant's feeding is an incomplete response to the problem.
D Increasing oxygen may alleviate symptoms, but medications such as digoxin and
furosemide are necessary to improve heart function and fluid retention. Notifying
the physician is the priority nursing action.
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Which of the following would be an appropriate intervention when caring for a client experiencing sensory overload?
a. Provide explanation of all procedures prior to implementation. b. Keep bright lights and the television on in the client's room to help orient her. c. Work as quickly as possible when performing tasks and procedures so the client has more time to rest. d. Encourage as many visitors as possible so the client does not feel lonely.
The nurse is caring for an older adult client who will be discharged home to live with an adult daughter. The client will be given prescriptions for four new medications for rheumatoid arthritis
How does the nurse ensure that the client will be able to take the medications correctly at home? a. Monitor the client self-administering me-dications while in the hospital. b. Include the client's daughter when teach-ing the client about the medications. c. Provide the client with pamphlets and in-formation about all the medications. d. Make a chart showing which medications the client should take at different times.
A hospitalized patient complains of acute chest pain, which he rates as a 9 on a scale of 0 to 10. The nurse administered a 0.4 mg sublingual nitroglycerin tablet, and now finds his vital signs to be stable. The nurse's next step is to
a. provide a second dose of nitroglycerin in 5 minutes. b. continue dosing at 10-minute intervals. c. obtain a transcutaneous pacer. d. increase the dose to 1 mg.
A modern approach to the development of clinical decisions and clinical judgments is the use of human patient simulators in simulation laboratories on campus. Human patient simulators are best described as:
A) life-sized mannequins with a sophisticated computer interface. B) Small, doll-like devices used for measuring vital signs. C) Health care equipment that has practice modes. D) Life-saving equipment that resuscitates clients in cardiac arrest.