Your institution uses electronic charting. Based on the assessment described, which of the
following systems would you mark as "abnormal" as you document your findings? For
abnormal findings, provide a brief narrative note.
What will be an ideal response?
X Abnormal
? Neurologic
? Respiratory: 28 breaths per minute, crackles in bases bilaterally. Spo2 78%; Pao2 74 mm Hg on 8 L
oxygen. Complaints of dyspnea at rest.
? Cardiovascular: HR 94 bpm with grade III systolic murmur. BP 176/102 . Peripheral pulses equal 4+ .
? GI:
? GU:
? Musculoskeletal
? Skin
? Psychosocial: Wife at bedside; concerned about patient status.
? Pain: Denies complaints of pain or the need for pain medication at this time.
? Neurologic
? Respiratory
? Cardiovascular
? Gastrointestinal (GI)
? Genitourinary (GU)
? Musculoskeletal
? Skin
? Psychosocial
? Pain
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When educating a client on the use of an adjuvant medication, which statement best demon-strates the nurse's understanding of this therapy?
a. "These medications are used instead of opioids to decrease the likelihood of ad-diction." b. "Adjuvant medications are prescribed be-cause they seldom cause any significant side effects." c. "These types of medications are used to eliminate the side effects of opioid medi-cations." d. "These drugs are used in combination with analgesics to increase the effect of the an-algesics."
A patient enters the emergency department alert and oriented after swallowing toilet bowl cleaner. The most appropriate treatment would be:
A) Administering syrup of ipecac B) Performing a gastric lavage C) Giving milk to drink D) Sending for a psychiatric consultation
When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find:
a. cyanosis. b. diuresis. c. signs of pulmonary congestion. d. increased oxygenation of the tissues.
Bethanechol:
1. Increases detrusor muscle tone to empty the bladder 2. Decreases gastric acid secretion to treat peptic ulcer disease 3. Stimulates voluntary muscle tone to improve strength 4. Reduces bronchial airway constriction to treat asthma