While the vital signs of a pregnant woman in her third trimester are being assessed, the client complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate?
a. Have the patient stand up and retake her blood pressure.
b. Have the patient sit down and hold her arm in a dependent position.
c. Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms.
d. Have the patient turn to her left side and recheck her blood pressure in 5 minutes.
D
Pressures are significantly higher when the patient is standing. Option a would cause an increase in systolic and diastolic pressures. Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension.
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Which of the following statements by your patient leads you to believe that he has understood how to safely and effectively use bulk-forming laxatives?
A) "I will mix the medication with around a cup of fluid and then drink the mixture." B) "I will mix the dry medication with applesauce and then eat prunes before bedtime." C) "I will use milk of magnesia in conjunction with Metamucil until I have a bowel movement." D) "I will decrease the roughage in my diet while I am taking the bulk-forming laxative and eat rice."
The nurse is planning a program for the unit's nurses related to the care and treatment of clients with osteoarthritis. Which of the following should be included in the presentation?
A) Hyperextension of muscle groups daily will promote flexibility. B) Avoid aerobic exercise. C) High-intensity isometric exercises are recommended every other day. D) Perform range-of-motion activities daily.
The client in a rehabilitation program has been using the bladder training techniques of the Valsalva and Credé maneuvers. When a nurse catheterizes this client immediately after voiding, the residual volume is 50 mL
What is the nurse's best action? A. Notify the physician. B. Insert an indwelling catheter. C. Document the finding as the only action. D. Modify or extend the bladder-training program.
Which of the following situations represents an accurate example of passive immunity?
a. The nurse who has received three doses of hepatitis B vaccine b. The parents who took their child to a neighbor's house to expose the child to the mumps c. The adult who received three doses of live antigen polio vaccine d. The newborn who had not yet received any immunizations