The nurse is assessing a woman in the immediate postpartum period. The patient's respiratory rate is 22 breaths/minute. The most important aspects of nursing care would be to do which of the following? (Select all that apply.)
A. Assess and provide pain management.
B. Assess the patient's blood pressure and pulse.
C. Increase the patient's fluid intake.
D. Notify the provider for continued tachypnea.
E. Provide ongoing physical assessment.
ANS: A, B, D, E
During the immediate postpartal period, the respiratory rate should remain within the normal range of 12 to 20 respirations per minute. However, slightly elevated respirations may occur due to pain, fear, excitement, exertion, or excessive blood loss. The nurse should assess and treat any pain. Taking the pulse and blood pressure can provide information on the patient's hemodynamic status. If tachypnea continues despite appropriate interventions, the provider should be notified. Ongoing physical assessment is part of postpartum care.
You might also like to view...
What laboratory marker would remain altered if a pancreatic pseudocyst is present?
A. Serum aspartate transaminase level B. Serum amylase level C. Serum bilirubin level D. Serum lipase level
Ivan W. is a 65-year-old man who is new to your practice. He has a history of COPD, CAD, hypertension, and type 2 diabetes mellitus. He has had no immunizations since his discharge from the military at age 25
Childhood diseases included chickenpox, measles, mumps, and "German measles." He presents for a disease management visit. Which of the following immunizations would you recommend for Ivan? A. MMR, influenza, pneumococcal, Zostavax B. Influenza, pneumococcal, PPD, Hepatitis B C. Tdap, pneumococcal, influenza, Zostavax D. Hepatitis B, influenza, pneumococcal, Hepatitis A
The nurse caring for a child with a new diagnosis of type 1 diabetes mellitus plans the care based on the understanding that:
a. There is an absolute deficiency of insulin b. Insufficient quantities of insulin are produced by the pancreas c. Oral hypoglycemic agents can control it d. Insulin deficiency is caused by another disease affecting the pancreas
The nurse mentions, "I like to use open-ended questions and statements because they result in fuller, more revealing responses by the client, and they stimulate discussion."
Based on this, which of the following is the nurse most likely to ask or say during client assess-ment? 1. "Where is your family?" 2. "Tell me about your family." 3. "Do you have a family?" 4. "Would you like to talk about your family?"