The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?
A) Low heart rate
B) Elevated blood pressure
C) Rapid respiration
D) Subnormal temperature
B
Feedback:
Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.
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The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most appropriate nursing response to this mother?
a. "Tell me how many hours per day your baby sleeps." b. "It is normal for newborns to sleep most of the day." c. "Newborns generally sleep 12 to 15 hours per day." d. "You will find as the baby gets older, he sleeps less."
The nurse is addressing an ethical issue. In which order should the nurse implement the steps of this decision-making process?
1. Interviewing the client regarding details of the problem 2. Discussing the various results of the identified possible actions to resolve the problem 3. Determining what, if any, ethical issues exist 4. Determining whether affected parties are in ethical conflict 5. Assessing all involved parties concerning their ethical beliefs regarding the problem
You are caring for Mr Grey in the PACU, who has undergone a transurethral resection of the prostate. He is bleeding more than usual for this type of procedure and you are concerned. When you contact the surgeon, Dr Michaels, and outline the details of Mr Grey's condition, she does not offer to review him. Using the STEP advocacy model, how will you respond to Dr Michaels?
What will be an ideal response?
The nurse is working with an adolescent client who will be admitted to the hospital in two days. Which nursing approach is most appropriate to prepare this client for hospitalization?
1. Have teens who have had similar experiences talk to the adolescent about hospitalization. 2. Provide an opportunity for the child to talk with an adult who has had a similar experience. 3. Teach parents what to expect so the information can be shared with the adolescent. 4. Provide an opportunity for the teen to try on surgical attire.