The nurse is monitoring a client who is in the hospital and has a fentanyl (Duragesic) patch in place for the control of breakthrough pain for breast cancer. What would be a concern for the nurse when she obtains vital signs for this client?
A) Temperature of 99° F
B) Blood pressure 100/60 mm Hg
C) Respiratory rate of 10 breaths/minute
D) Heart rate of 96 beats/minute
C
Feedback:
The nurse should not administer this medication if the respiratory rate is less than 12 breaths/minute. The temperature, blood pressure, and heart rate are within normal range.
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The nurse is planning to inspect a patient's apical heart impulses. What should the nurse do to ensure that this body organ is optimally assessed?
A) Use perpendicular lighting. B) Use tangential lighting. C) Focus a penlight on the patient's chest. D) Assist the client to a standing position.
The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority?
a. Skin integrity b. Blood pressure c. Heart rate and rhythm d. Abdominal percussion
The nurse is caring for a suicidal patient who has been treated effectively with antidepressant therapy. The patient verbalizes that he feels better. The nurse is alert that the patient is most at risk for which potential complication?
a. Increased risk of self-harm b. Increased emotional fragility c. Increased potential for weight gain d. Increased activity intolerance
Which of the following statements is true of mental health care in the United States today?
A) At least 75% of the homeless population has a severe and persistent mental illness. B) Managed care has effectively reduced the cost of mental health treatment by one third. C) Only 25% of people needing mental health services are receiving those services. D) One fourth of people who are incarcerated have a major mental illness.