Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss?
A) Vital sign sheet
B) Intake and output sheet
C) Critical care flow sheet
D) Health assessment flow sheet
Ans: B
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A 76-year-old patient is receiving IV heparin 5,000 units every 8 hours. An activated thromboplastin time (aPTT) is drawn 1 hour before the 8:00 AM dose; the aPTT is at 3.5 times the control value. What is the nurse's priority action?
A) Give a larger dose to increase the aPTT. B) Give the dose as ordered and chart the results. C) Check the patient's vital signs prior to administering the dose. D) Hold the dose and call the result to the physician.
A patient is cleaning the garage and splashes a chemical in his eyes. The initial priority after the chemical burn is to
a. transport to a physician immediately. b. cover the eyes with a sterile gauze. c. irrigate with H2O for 15 minutes or longer. d. irrigate with normal saline solution for 1 to 5 minutes.
The following criterion is considered a positive finding when determining whether a patient with asthma can be safely monitored and treated at home:
A. Age over 40 B. Fever greater than 101 C. Tachypnea greater than 30 breaths/minute D. Productive cough
The nurse is inserting a nasogastric (NG) tube and assessing the patient during the procedure. Which assessment finding indicates a potentially serious problem?
a. Restlessness b. Inability to speak c. Nasal pressure d. Mouth breathing