The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54, P 102, RR 22 . The nurse recognizes these symptoms as indicative of:
a. inadequate perfusion.
b. circulatory shock.
c. massive vasodilation.
d. heart failure.
B
Shock results from failure of the circulatory system to provide sufficient blood circulation.
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An IV solution originally scheduled to run at 75 mL/hr is behind schedule. The drop factor for the IV tubing is 10 gtt/mL. Agency policy allows a 25% increase in the base rate if there are no contraindications
Recalculate the gtt/min when this increase is put into effect. _____ a. 56 b. 16 c. 94 d. 19
A nurse explains the reasons why certain nursing interventions are to be performed on a client. The nurse is aware that this type of teaching is:
a. formal c. kinesthetic b. informal d. learning
Which statement is true about Z track technique for intramuscular injections?
A) The ventrogluteal site is used to prevent medication from seeping into the needle tract and onto the skin. B) Inject the needle at 90 degree angle, and after giving the injection, count to 10 prior to removal of the needle. C) After preparing the medication, use the same needle to prevent leakage along the tract of the injection. D) Add 0.1 mL of air to the syringe to seal off the medication and prevent it from leaking onto the skin.
The nurse is caring for a client with a large open wound. While doing the dressing change, the nurse notes purulent drainage. What additional assessments are necessary for this client? Select all that apply
1. White blood count 2. Fever 3. Wound odor 4. Wound bleeding 5. Blood urea nitrogen (BUN) CHART 67–10