A woman in labor has just received an epidural block. The most important nursing inter-vention is to:
a. Limit parenteral fluids.
b. Monitor the fetus for possible tachycardia.
c. Monitor the maternal blood pressure for possible hypotension.
d. Monitor the maternal pulse for possible bradycardia.
C
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A Intravenous fluids are increased for a woman receiving an epidural to prevent hypotension.
B The nurse observes for signs of fetal bradycardia.
C The most important nursing intervention for a woman who has received an epi-dural block is to monitor the maternal blood pressure frequently for signs of hypotension.
D The nurse monitors for signs of maternal tachycardia secondary to hypotension.
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A client has been placed in seclusion. Which client behavior would have warranted this intervention?
1. The client is manic, has been flirtatious towards staff and refused morning medication, and has verbalized a plan to leave 2. The client is psychotic, sits in the corner with hands over ears, and displays increased suspiciousness of and agitation towards others despite recently receiving 1mg risperidone (Risperdal) PRN 3. The client is depressed and wants to be left alone to rest 4. The client is suicidal, has been banging head against the table in the day room, and was unresponsive to staff's verbal redirection
A nurse is concerned that a child with pulmonary hypertension (PA) is developing heart failure. Which manifestation would the nurse assess for first?
A. Cough B. Dyspnea C. Extremity edema D. Tachycardia
The overall goal of client advocacy is to:
1. safeguard the client's right to privacy by judiciously protecting confidential information. 2. safeguard the public when health care and safety are affected by incompetent, unethical, or illegal practice of any person. 3. provide services with respect for human dignity and the uniqueness of the client. 4. ensure that the client receives the best possible care and to support the client's right to have health care consistent with the client's values and beliefs.
Iona has been brought to the clinic for her well-child checkup and immunizations. When the nurse completes the assessment, Iona is noted to have a low-grade fever. The nurse knows that:
1. Iona should not receive the immunizations because her body is ill. 2. Iona can receive the immunizations since the fever is low grade. 3. Iona can receive the immunizations because the low-grade fever will increase the effectiveness of the vaccine. 4. It is important to remain on schedule with the immunizations.