In the recovery room, if a woman is asked to either raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see if she:
1. has recovered from epidural or spinal anesthesia.
2. has hidden bleeding underneath her.
3. has regained some flexibility.
4. is a candidate to go home after 6 hours.
1
1. Correct. If the numb or prickly sensations are gone from her legs after these movements, she likely has recovered from the epidural or spinal anesthesia.
2, 3, 4. Incorrect. If the numb or prickly sensations are gone from her legs after these movements, she likely has recovered from the epidural or spinal anesthesia.
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A nurse reads in the chart that a baby has a positive crossed extension reflex and asks a more experienced nurse to demonstrate this assessment. How does the nurse perform the assessment?
A. Place the infant supine, stimulate one foot, and watch for reaction of the other leg. B. Tap the infant's forehead gently, and assess for blinking for the first few taps. C. Watch the infant attempt to crawl when he is placed on his abdomen. D. With the infant prone, stroke one side of the spine; watch the buttocks curve toward the stimulation.
The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. The next action for the nurse would be to
a. leave and get help. b. take the patient's temperature. c. give him his nose spray. d. stop the transfusion and IV administer saline.
When caring for the client in septic shock, the nurse recognizes fluid replacement is inadequate when which of the following is noted?
1. Urine output 10 milliliters for the last hour 2. Pulse rate of 100 beats per minute 3. MAP 75 4. Central venous pressure is 5 mmHG
Ms. L is actively dying and has refused oral intake. Her caregiver is concerned. Which of the following responses would be the most helpful to the caregiver?
1. "Offer her fluids every hour, but respect her right to refuse." 2. "Let's see if we can obtain an order for an antipyretic suppository." 3. "Dehydration is not painful and eases the passage from life. Offer sips of fluid upon request." 4. "Put some fluid into her mouth every half hour and see if she will swallow it."