The nurse determines that a patient with hypovolemic shock is improving. What did the nurse observe to come to this conclusion? (Select all that apply.)
a. Heart rate increasing
b. Respiratory rate increasing
c. Present of peripheral pulses
d. Systolic blood pressure increasing
e. Urine output 20 mL over the last hour
ANS: C, D
Perfusion is first evident in peripheral pulses. An increase in blood pressure occurs because of an improvement in circulating blood volume. A. B. Increasing heart and respiratory rates indicate that the patient is not improving. E. A urine output of less than 30 mL per hour indicates insufficient perfusion of the kidneys caused by the shock.
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The nurse is teaching a patient with asthma how to measure peak expiratory flow rate (PEFR). What should be included in the teaching plan? (Select all that apply.)
a. Assume a recumbent position before measuring PEFR. b. Take a deep breath in, exhale, then place the mouthpiece in the mouth and form a firm seal with the lips. c. After placing the mouthpiece in the mouth, blow out as hard and as fast as possible through the mouth in only one single breath. d. Measure PEFR 3 times and record the highest number.
Which activity will be most useful to a nurse wishing to provide evidence-based psychiatric nursing care?
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A client has genital herpes simplex 2. The nurse teaches the client that:
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