The nurse assessing a postoperative patient discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. What can the nurse determine is indicated by these findings?
a. Pain shock
b. Dehydration
c. Internal hemorrhage
d. Acute infection
ANS: C
If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage.
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The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal?
A) Recover from the general anesthesia B) Decrease nausea and vomiting C) Increase the amount of fluids D) Ambulate independently
Which drop factor allows the greatest volume of intravenous fluid to be delivered per hour at a drip rate of 50 gtt per minute?
a. 10 b. 15 c. 20 d. 60
A nurse manager has begun working in an organization with decentralized decision making. Decentralized decision making allows the nurse manager to:
a. Make decisions effectively b. Make long-range plans c. Develop organizational goals d. Initiate policy development
In a motor vehicle crash, a patient suffers a skull fracture, possible cervical spine injury, multiple extremity fractures, and a large thermal burn. On initial admission to the emergency department, what is the nursing priority of care?
A) Intravenous fluid resuscitation B) Protection from infection C) Assessment of extent of burns D) Protection of airway and cervical spine