Which statement best identifies indicators of acute pain?
A. Decreased pulse rate and respiratory rate, and increased blood pressure
B. Increased pulse rate, respiratory rate, and blood pressure
C. Respiratory rate and blood pressure are normal
D. Client is calm; pupils are contracted
Ans: B. Increased pulse rate, respiratory rate, and blood pressure
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A patient becomes unresponsive. The patient's heart rate is 32 beats/min, idioventricular rhythm; blood pressure is 60/32 mm Hg; SpO2 is 90%; and respiratory rate is 14 breaths/min. Which of the following interventions would the nurse do first?
a. Notify the physician and hang normal saline wide open. b. Notify the physician and obtain the defibrillator. c. Notify the physician and obtain a temporary pacemaker. d. Notify the physician and obtain a 12-lead ECG.
The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode is to:
a. assess fetal heart rate and maternal vital signs. b. perform a venipuncture for hemoglobin and hematocrit levels. c. place clean disposable pads to collect any drainage. d. monitor uterine contractions.
The nurse is caring for an older patient who has been the victim of elder abuse by an adult son. According to the transgenerational violence theory of elder mistreatment, which situation would have occurred with the patient?
1. The son is an alcoholic. 2. The care of the patient has overwhelmed the son. 3. The patient was abusive to the son when he was a child. 4. As a child, the son witnessed the father beating the mother.
A patient is in sinus tachycardia. Which nursing interventions are appropriate?
Select all that apply. 1. Observe the patient for effects on cardiac function. 2. Administer two tablets of acetaminophen (Tylenol) per physician prescription if an elevated temperature is present. 3. Administer normal saline 0.9% IV at the prescribed rate of 200 mL per hour if hypovolemia is suspected as the cause. 4. Give pain medications as prescribed if pain is present. 5. Give atropine per physician prescription to slow the heart rate.