The nurse caring for a client who has had AAA repair would be most alarmed by which finding?
A. Urine output of 20 mL over 2 hours
B. Blood pressure of 106/58
C. Absent bowel sounds
D. +3 pedal pulses
Answer: A. Urine output of 20 mL over 2 hours
You might also like to view...
When performing an assessment of the integumentary system on a client, the nurse should:
1. palpate for edema over the knee. 2. inspect the inside of the mouth for skin tags. 3. check color, quantity, and distribution of hair. 4. check for skin turgor on the forearm.
The nurse enters a patient's room and notes he is nauseous, vomiting, and experiencing abdominal pain, and has no bowel sounds
She concludes that the patient's symptoms may be associated with a paralytic ileus. In arriving at this conclusion, the nurse has used: a. Inductive reasoning b. Deductive reasoning c. Guesswork d. Diagnostics
The informatics nurse is on a committee that is designing the patient criteria for connected care. Which should be kept in mind when determining inclusion and exclusion criteria?
A) Almost all patients can be included. B) Psychiatric patients are to be excluded. C) Only patients with chronic illnesses should be excluded. D) All patients should be evaluated on a case-by-case basis.
The nurse is teaching a family member how to suction the client's tracheostomy at home. Which information does the nurse include in the teaching plan?
a. Always suction using sterile technique. b. Suction the mouth first and then the airway. c. Be prepared to recannulate the tube frequently. d. Suctioning with clean technique is acceptable.