The nurse knows the following indicates orthostatic hypotension: (Select all that apply.)
a. A decrease in systolic blood pressure by 30 mm Hg
b. A decrease in diastolic blood pressure by 10 mm Hg
c. An increase in heart rate by 30 beats/min
d. An increase in systolic blood pressure by 20 mm Hg
ANS: B, D
A drop in systolic blood pressure of 20 mm Hg, an increase in heart rate of 20 beats/min, or a drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension.
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An elderly woman's poor nutritional status, low body mass index, and impaired mobility have put her at a high risk for developing pressure ulcers
This client's nurse should prioritize which of the following actions in order to prevent her development of pressure ulcers? A) Drag the client slowly and carefully when repositioning. B) Massage skin regions that have early signs of skin breakdown. C) Maintain the client's hygiene and wash her frequently with soap. D) Ensure that the client's position is changed frequently and regularly.
The nurse would clarify to a client that sinus arrest differs from sinus block in that with sinus arrest, the
a. atrial focus totally takes over pacing responsibility. b. atrioventricular (AV) node is the primary pacemaker. c. rhythm is regular. d. sinoatrial (SA) node occasionally fails to fire.
The inner potential humans have for healing, growth, and well-being throughout the lifespan is broadly defined by Reed as
A. Nursing processes. B. Self-organization. C. Developmental process. D. Well-being processes.
The nurse is teaching the parents how to prepare a mixed dose of insulin. Which of the following instructions is correct?
a. Have insulin at room temperature to decrease pain b. Shake the bottle of cloudy insulin c. Draw up NPH first d. Inject air into the regular insulin first