A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. Based on these findings, what is the most appropriate nursing action?
A. Recheck the vital signs in 1 hour
B. Notify the nurse-midwife of the findings
C. Continue collecting subjective and objective data
D. Document the findings in the client's medical record
Ans: B. Notify the nurse-midwife of the findings
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The nurse is providing a psychotropic medication to an older client. Which findings are most concerning to the nurse? Select all that apply.
1. Intermittent, repetitive muscle movements 2. Frequent crossing and uncrossing of legs 3. Belief that a hooded figure is watching 4. Continual lip smacking and tongue movements 5. Disorganized speech and catatonic behavior
The nurse reinforces that the purpose of preoperative medication is to: (Select all that apply.)
a. reduce anxiety. b. decrease mucus secretion. c. counteract nausea. d. synergize anesthesia. e. enhance ventilation.
Intake and output are totaled:
a. Every 2 hours b. Every 4 hours c. At the end of the shift d. At least once during an 8-hour shift
An older adult has been prescribed an aminoglycoside antibiotic. The nurse would immediately contact the physician if the client exhibits which symptoms?
Standard Text: Select all that apply. 1. High-pitched tinnitus 2. Vertigo 3. Nausea and vomiting 4. Diarrhea 5. Rash