Select the action by the nurse that has the highest priority in the care of several clients who are receiving postoperative pain management by epidural analgesia on the surgical unit
a. Change the IV tubing with each bag of medication.
b. Keep the head of the bed elevated 30 de-grees to prevent hypotension.
c. Monitor peripheral pulses every 2 hours.
d. Assess for movement and sensation of the feet and legs each shift.
D
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When the patient with sleep apnea says, "I'm not wearing that silly mask. I look like something out of ‘Star Wars'." The nurse reminds the patient that the mask:
1. increases oxygen intake. 2. stimulates regular respirations. 3. sounds an alarm when the oxygen concentration drops. 4. uses positive pressure to keep the airway open.
On assessment, a nurse notes that a patient's pulse is weak and applying light pressure causes it to disappear. What pulse amplitude would the nurse document on the flow chart?
A) 1+ B) 2+ C) 3+ D) 4+
A client has been on the unit for an evaluation. A hearing for this client was scheduled and held. The outcome was a ruling of incompetence. What is the next likely step?
a. A conservator will be appointed to handle the client's affairs. b. The client will be accorded the right to refuse treatment and refuse medications. c. The client will need to stand trial for the M'Naghten test. d. The nursing staff will need to seclude the client.
The nurse assumes responsibility for a blood transfusion that was initiated 2.5 hours ago. The patient is tolerating the procedure well, and there is roughly 50% of the blood remaining. The best action by the nurse is to
1. Increase the transfusion rate. 2. Stop the infusion and return the unused blood to the blood bank. 3. Chart the current vital signs. 4. Notify the charge nurse.