Which lab result would require immediate intervention by the nurse for the client scheduled for surgery?
1. Calcium 9.2
2. Bleeding time 2 minutes
3. Hemoglobin 15
4. Potassium 2.4
4. Potassium 2.4
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When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.
A nurse is considering reporting suspected abuse by a step-father, but she is worried that she might jeopardize a developing relationship with the child's mother. What legal ramifications should she consider?
1. If she does not report her suspicions, she could lose her license. 2. If she makes a report, the step-father could sue her for false arrest. 3. If she makes the report, the mother could accuse her of alienation of affection. 4. If she does not make a report, her agency could be liable for any medical expenses.
A 71-year-old woman with a history of rheumatoid arthritis and chronic heart failure has been admitted to the hospital for the treatment of a suspected upper gastrointestinal bleed
When performing an assessment of this patient, which of the following questions most directly addresses a likely cause of the woman's bleeding disorder? A) "How closely do you tend to monitor your blood pressure when you're at home?" B) "Has your doctor prescribed a water pill for your heart failure?" C) "Do you ever take aspirin to treat the pain of your arthritis?" D) "Did either of your parents or siblings have problems with bleeding?"
The acute phase of the burn begins 48 to 72 hours after the burn. What begins at this time?
A) Cardiac output decreases B) Renal failure begins C) Diuresis D) Fluid moves from intravascular compartment to interstitial spaces