The nurse is providing care for a patient whose right atrial pressure (RAP) is 12 mm Hg. Which action should the nurse take?
a. Assess skin turgor.
b. Listen to breath sounds.
c. Measure urine specific gravity.
d. Determine level of consciousness.
ANS: B
Normal RAP is 2 to 6 mm Hg. This pressure reflects fluid volume status, so an increased level indicates heart failure. The heart is not pumping effectively, so blood is backing up, raising the RAP reading and placing the patient at risk of pulmonary edema. A. C. D. These actions would not be indicated for this pressure reading.
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The nurse is giving a health promotion class to adolescents. In counseling an adolescent about lifestyle choices, the nurse discusses the fact that the most preventable cause of adult death in the United States is:
1. Alcohol use. 2. Obesity. 3. Tobacco use. 4. Cocaine use.
The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient?
a. The patient would be considered totally blind. b. This patient probably has some light perception, but no usable vision. c. This patient has some usable vision, which enables function at an acceptable level. d. The nurse would need to determine how this patient's visual impairment affects normal functioning.
The RN is delegating tasks to the unlicensed assistive personnel (UAP). Which tasks can the nurse delegate? (Select all that apply.)
a. Teaching the client about breast care b. Assessment of a client's lochia and perineal area c. Assisting a client to the bathroom for the first time after birth d. Vital signs on a postpartum client who delivered the night before e. Assisting a postpartum client to take a shower on the second postpartum day
To prevent medication transcription errors, all the following rules should be observed except:
a. always place a zero before a decimal number less than 1. b. never place a decimal and extra zeros after a whole number. c. avoid using decimals when whole numbers can be used as alternatives. d. use grains as units of measurement for p.o. medications whenever possible.