A new nurse is having a difficult time knowing which client should be seen first because they all seem important. The nurse preceptor helps and explains that the client with which of the following should be seen first?
a. Dizziness with normal vital signs
b. Hypotension, tachycardia, and lethargy
c. Abdominal pain, hypertensive and constipated
d. Febrile, tachycardia, and vomiting
b. Hypotension, tachycardia, and lethargy
rationale: The hypotensive client with tachycardia is concerning for hypovolemia or shunting, especially with lethargy. This client is not stable. The lethargy indicates that blood flow and oxygenation are an issue.
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A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?
A) Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious. B) Give the patient a sterile tongue depressor to use for scratching instead of the pencil. C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists. D) Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.
An example of veracity is:
a. being first in line c. having a great deal to do b. volunteering to work overtime d. admitting mistakes promptly
The nurse carefully monitors the obese hysterectomy patient for the peculiar postoperative complications associated with obesity (select all that apply):
1. Nausea 2. Vomiting 3. Hypertension 4. Hemorrhage 5. Respiratory difficulties
A 20-year-old patient is experiencing difficulty with near vision. The nurse realizes that this finding is:
1. consistent with the aging process. 2. normal in a 20-year-old patient. 3. evidence of presbyopia. 4. evidence of hyperopia.