The nurse is assisting a client to walk in the hall on the third day after a myocardial infarction. Which clinical manifestation indicates to the nurse that the client is not ready to advance to the next level of activity?
a. Facial flushing
b. Onset of chest pain
c. Heart rate increase of 10 beats/min at completion of the activity
d. Systolic blood pressure increase of 10 mm Hg at completion of the activity
B
Chest pain on ambulation indicates poor tolerance to activity and is an indication that the heart is not ready for progression. The other manifestations indicate that the client is tolerating the activ-ity.
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The nurse teaches the patient who has been diagnosed with oxalate renal calculi which of the following nutritional guidelines?
A) Restrict protein intake to 60 g/d. B) Restrict sodium intake to 5 to 6 g/d. C) Follow a low-calcium diet. D) Encourage intake of oxalates (peanuts, wheat bran, strawberries, rhubarb, tea, and spinach).
Assessment of vital signs in the elderly reflect
A. Errors in blood pressure measurement are rare with automated recording devices B. Shortness of breath in the elderly is rare in the older, deconditioned, and immobile patient C. Older adults prefer a 0-10 pain rating scale D. Older adults could be septic with a temperature within normal limits
A 38-week newborn is found to be small for gestational age (SGA). Which of the following nursing interventions should be included in the care of this newborn?
A. Monitor for feeding difficulties. B. Assess for facial paralysis. C. Monitor for signs of hyperglycemia. D. Maintain a warm environment.
The nurse answers the patient's call light to find the patient agitated and stating that she "felt something pop." The nurse finds that the patient's abdominal surgical wound has eviscerated. What should the nurse do?
a. Try to reinsert the abdominal contents. b. Cover the wound with a dry sterile dressing. c. Notify the surgeon when he makes rounds. d. Cover the wound with a moist saline dressing.