A nurse is preparing to administer a blood transfusion. Which assessment finding would the nurse report immediately?
a. Blood pressure 120/60
b. Temperature 101.3° F
c. Poor skin turgor and pallor
d. Heart rate of 100 beats per minute
B
A fever should be reported immediately, and the blood transfusion may be postponed. All other assessment findings are acceptable before starting a blood transfusion.
You might also like to view...
What is the purpose of adult day health centers?
a. Provide support of life until death occurs b. Provide assistance to people who may need help with activities of daily living (ADLs) c. Provide treatment for those needing reha-bilitation d. Provide respite care relief for caregivers
The nurse has completed parent education related to treatment for a child with congenital clubfoot. The nurse knows that parents need further teaching when they state
1. "We're happy this is the only cast ourbaby will need." 2. "We'll watch for any swelling of thefeet while the casts are on." 3. "We'll keep the casts dry." 4. "We're getting a special car seat toaccommodate the casts."
The nurse is caring for a patient who has myasthenia gravis (MG) and is receiving pyridostigmine bromide (Mestinon). The nurse notes ptosis of both eyelids and observes that the patient has difficulty swallowing. What action will the nurse perform next?
a. Contact the provider to request an order for atropine sulfate. b. Contact the provider to request an order for edrophonium chloride (Tensilon). c. Report signs of cholinergic crisis to the provider. d. Report signs of myasthenic crisis to the provider.
Which should the nurse include in the plan of care for the patient with Parkinson's disease?
A. Monitor the client for the ability to chew and swallow. B. Check peripheral circulation for thrombophlebitis. C. Monitor the client for psychotic symptoms. D. Limit exercise to decrease the possibility of fractures.