The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first?
a. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago
b. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due
c. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating
d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
ANS: D
The frequent firing of the ICD indicates that the patient's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered.
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1. Have the step-parent sign the informed consent. 2. Have the patient sign the informed consent. 3. Obtain the custodial parent's signature on the informed consent. 4. Solicit the signature of the noncustodial parent on the informed consent.
An older adult reports being dizzy when getting up too quickly from a sitting posi-tion. Which intervention will be appropriate in monitor the client's blood pressure
a. Positioning the client in a supine position for the assessment b. Taking 3 blood pressure assessments 5 minutes apart c. Arranging for the client to have ambulatory blood pressure monitoring d. Taking the blood pressure both manually and electronically to compare read-ings
The nurse instructing a client with allergic rhinitis would recommend which actions to decrease exposure to allergens?
Standard Text: Select all that apply. 1. Remove pets from the home or limit exposure. 2. Routinely clean moldy surfaces. 3. Clean frequently to remove dust mites from bedding, carpets, and furniture. 4. Remove all carpeting and replace with wood floors. 5. Buy new mattresses every 2 years.
If a patient shows signs of delusions or hallucinations, you should
A. agree with the patient. B. avoid reinforcing the patient's false beliefs. C. keep the patient in her room to avoid violence. D. avoid contact with the patient unless absolutely necessary.