Nifedipine (Procardia), the most potent calcium blocker, promotes vasodilation of the coronary and peripheral vessels. While the client is taking the drug, the nurse's highest priority intervention is to monitor for:
a. elevated blood pressure.
b. decreased blood pressure.
c. pulse rate less than 70 beats/minute.
d. pulse rate greater than 120 beats/minute.
ANS: B
Nifedipine causes hypotension.
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The nurse is asked to obtain informed consent for surgery that will be performed on a client the following day. The appropriate action is:
1. Explaining the procedure to the client, and having the client sign the form. 2. Witnessing the signature, not whether the client understands what will occur. 3. Having the client sign a blank form that the physician can fill out later. 4. Having a family member talk to the patient to convince him to have the procedure.
A patient is scheduled to see an acupuncturist as complementary treatment for back pain. What should the nurse instruct the patient to expect when seeing the acupuncturist for the first time? (Select all that apply.)
a. The patient's tongue will be examined. b. The patient's pallor will be assessed. c. The patient's voice and scent will be assessed. d. The patient's blood pressure will be measured. e. The patient's peripheral pulse will be checked.
A wound that would require a high-pressure cleansing is one that has:
A. Granulation tissue present B. Minimum serosanguineous exudate C. Eschar or necrotic tissue present D. Minimum residue from wound care products
A nurse is caring for a client who has to be prevented from scratching an open wound
The physician has ordered wrist restraints for the client. What should the nurse do when restraining the client's hands using soft wrist protective devices? A) Bring both ends of the tie together and attach them to the side rails B) Apply the padded portion of the device around the wrist C) Attach both the straps on the same side of the chair D) Attach the restraint only to the wrist closest to the wound