A 22-year-old male is in the ICU with sepsis. The physicians are trying to rule out acute DIC. The nurse performs a primary assessment of the patient at the beginning of shift
Which of the following items would be part of the initial assessment for this patient? Select all that apply.
A) Check for signs of bleeding in the gums and/or mouth.
B) Check pupils for reaction.
C) Check IV sites or any areas where the patient may have had labs drawn for bleeding.
D) Check for altered level of consciousness.
A, B, D
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Which of the following factors will result in a shift of the oxyhemoglobin dissociation curve to the left?
a. Increased PaCO2 c. Increased temperature b. Increased pH d. Increased 2,3-DPG
An adult patient who experiences angina pectoris with exertion is informed by the nurse that most often angina is caused by:
A) Smoking B) Inadequate cardiac output C) Infarction of the myocardium D) Coronary arteriosclerosis
Which of the following is an example of a measurable outcome for the patient who has undergone a surgical procedure with a pain rating of 7 on a scale of 0 to 10?
a. Patient's pain will be under control by Sunday. b. Patient will have no pain by the end of this shift. c. Patient's pain will decrease by the end of shift on (date). d. Patient's pain will decrease to 2 or lower by the end of shift on (date).
Because the patients are attending role modification classes, the nurse assesses this family as being at the developmental stage of:
1. beginning families. 2. families with young children. 3. families with adolescents. 4. families in later life.