The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs). Because of this, the nurse should
a. Make sure that elastic stockings are not removed.
b. Measure the calf circumference of both legs.
c. Dorsiflex the foot while assessing for patient discomfort.
d. Measure both ankles to determine size.
B
Measure bilateral calf circumference and record it daily as an assessment for DVT. Homans' sign, or calf pain on dorsiflexion of the foot, is contraindicated in patients when a DVT is suspected. It is no longer a reliable indicator in assessing for DVT, and it is present in other conditions. Remove the patient's elastic stockings and/or sequential compression devices (SCDs) every 8 hours, and observe the calves for redness, warmth, and tenderness. Bilateral calf circumferences (not ankle) should be measured daily to detect unilateral increases that may be an early indication of thrombosis.
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Initial management of laryngospasm includes
a. intubating the patient and providing manual ventilation with 100% oxygen. b. hyperextending the patient's head and administering positive-pressure ventilations on 100% oxygen. c. administering 10 mg of succinylcholine. d. administering nebulized racemic epinephrine.
A pregnant patient is being induced with oxytocin, which has been infusing for 1 hour. The initial rate was 6 milliunits/min, and the rate now is 18 milliunits/min
The nurse notes regular contractions occurring every 3 minutes, each lasting 35 seconds. The nurse will: a. increase the rate of infusion by 1 to 2 milliunits/min every 15 to 40 minutes. b. increase the rate of infusion by 3 to 6 milliunits/min every 15 to 40 minutes. c. interrupt the infusion and continue to monitor the patient before restarting. d. interrupt the infusion and notify the provider of potential oxytocin toxicity.
A 2-year-old has been admitted to the pediatric unit with a 2-day history of vomiting and diarrhea. Which of the following would be a cue the nurse identifies as being outside the normal standard?
1. The child's weight is 25 lb. 2. The child cries when parents leave the room. 3. The child is not able to stand alone. 4. The child is able to hold finger foods.
Bleeding and arterial occlusion could occur following percutaneous coronary interventions
a. true b. false