The nurse would measure vital signs more frequently than every 4 hours for which of the following clients?
1. The client with a diagnosis of terminal cancer admitted for palliative care
2. The client who is 6 days postoperative and is to be discharged tomorrow
3. The client admitted as an outpatient for 12 hours while receiving a blood transfusion
4. The client who is 36 hours postoperative and stable
3
Rationale: A client receiving blood transfusions requires vital signs before beginning the transfusion, 15 minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed. The other clients would require vital signs every 4 hours unless a complication or change in condition arose.
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Which postoperative observation must be reported to the physician immediately?
a. Brownish-red drainage on the dressing, which is damp b. Respirations of 20 breaths/min c. Pulse of 72 beats/min d. Bright-red bleeding
When handling cytotoxic agents the nurse should:
a. wear gloves at all times when handling these agents. b. mop up spills or leaks with absorbable paper towels. c. call housekeeping to clean up any spills. d. notify the health care provider immediately if spills occur.
A nursing manager of the medical–surgical unit is rewarding the staff for exceptional job performance. Which should the nurse expect if the manager chose extrinsic rewards? Select all that apply
1. Opportunities to gain experience 2. Increased job satisfaction 3. Improved ability 4. Increased recognition 5. Time off for conferences
For a male client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
a. Cool, clammy skin b. Distended neck veins c. Increased urine osmolarity d. Decreased serum sodium level