The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following?
1. Temperature 97.9°F
2. Respirations 68 breaths/minute
3. Vital signs stable for only 2 hours
4. Heart rate 156 beats/min
2
Explanation: 2. The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-than-ideal transition.
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The hospice nurse instructs caregivers in repositioning the patient because the patient spends most of the time reclining, which can lead to:
a. contractures. b. pressure ulcers. c. bruising. d. excoriation.
The most effective way to assess the quantity of pain is to ask the patient to
a. describe the pain as minor, moderate, or severe. b. classify the pain as small, medium, or large. c. rate the pain on a scale from 0 to 10. d. compare the pain with pain experienced in the past.
Strong opioids are most likely to cause which acid-base disturbance?
a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
The client asks whether herbal medicines are a "good idea." The nurse's best response is:
1. "Things found in nature are always healthy." 2. "If your doctor didn't prescribe it, don't take it." 3. "Are there specific ones you're wondering about?" 4. "Everything is good in moderation."