While transferring a patient with heart failure from the bed to a chair the nurse stops and decides to keep the patient in bed
What patient manifestations indicated to the nurse this patient's status was deteriorating? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Respiratory rate 30
2. Heart rate 134 on the cardiac monitor
3. Gasping for breath
4. Productive cough
5. Jugular vein distention
1,2,3
Rationale 1: Tachypnea is an indication of worsening heart failure.
Rationale 2: Tachycardia is an indication of worsening heart failure.
Rationale 3: Dyspnea is an indication of worsening heart failure.
Rationale 4: A productive cough is not an indication that the heart failure is becoming worse.
Rationale 5: Jugular vein distention is not an indication that the heart failure is becoming worse.
You might also like to view...
The nurse is caring for a client with major depressive disorder who was recently placed on a high-potency neuroleptic (antipsychotic) medication. The client has not been eating well, is starting to get dehydrated, and has a temperature of 101°F
The physician orders antibiotics. Six hours later, the nurse notice that the client's temperature has risen to 103°F, and the client has muscle rigidity, and a fluctuating blood pressure. The priority of action for the nurse is to: 1. Discontinue neuroleptic and report symptoms to physician immediately. 2. Chart the assessment findings and report them to the primary nurse at change of shift. 3. Discontinue the neuroleptic and document assessment findings as cause for the action. 4. Continue the medications and perform more frequent assessments of the client.
The nurse should exercise caution when administering antimetabolites to a patient diagnosed with what?
A) Bone marrow suppression B) Diabetes mellitus C) Hypertension D) Seizure activity
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?
A) Fluoroscopy B) Chest x-ray C) Magnetic resonance imaging (MRI) D) Computed tomography (CT) scan
Using Piaget's theory of cognitive development, the nurse expects preschoolers will: Standard Text: Select all that apply
1. Be egocentric and fail to see another's point of view. 2. Focus on many aspects of a given situation at once. 3. Assume everyone else in their world sees things as they do. 4. Believe they have magical powers of thought to control the universe. 5. Understand cause-and-effect relationships