When a client undergoing treatment for severe preeclampsia complains of epigastric pain, the nurse should notify her health care provider immediately because the client is:
a. having a reaction to her medications c. going into labor
b. reverting to mild preeclampsia d. moving into eclampsia
D
In severe preeclampsia, the blood pressure increases to 160/110 . Weight gain may be 2 pounds within a few days, with urinary albumin of 3+ to 4+. Common symptoms include continuous headache, blurred vision, scotomata, nausea, vomiting, irritability, hyperreflexia, cerebral disturbances, dyspnea, cyanosis, pulmonary edema, and epigastric pain. If eclampsia occurs, the client may have a grand mal seizure and go into a coma.
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A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.)
a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.
What nursing consideration is most important in the care of a child on a mechanical ventilator?
a. Humidification is not necessary. b. Respiratory assessment is done by the ventilator. c. Positioning the child for comfort and optimum ventilation is necessary. d. Support and reassurance are not as important because the child is unconscious.
A patient is scheduled to receive a vaccination but is experiencing a mild upper respiratory infection. Which of the following should the nurse do?
1. Administer the vaccination. 2. Schedule the patient to return in 1 month for the vaccination. 3. Tell the patient that the vaccination is no longer needed. 4. Administer half of the vaccination and schedule the patient to return in 1 week for the remainder of the dose.
As a nurse working in a unionized environment, the appropriate process for you to follow if you have an issue of concern is to __________
a. file a grievance; meet with your manager to discuss; and attend arbitration, if needed b. file a grievance; speak with your union representative; and speak with your manager c. speak with your manager; speak with administration; and file a grievance d. speak with your manager; file a grievance; and attend arbitration, if needed