A patient is in the compensatory stage of shock. What symptoms displayed by the patient would indicate the need to implement immediate nursing action?
a. Irritable and restless
b. Listless and confused
c. Unconscious
d. Anxious and fearful
A
An irritable and restless patient is at definite risk for falling or hurting him- or herself.
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When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:
A) Choose a proximal site. B) Choose a distal site. C) Have the patient hold his arm over his head. D) Leave the tourniquet on for at least 5 minutes.
A nurse is providing patient education to a 45-year-old man who is taking cyclosporine (Sandimmune). The nurse will provide the patient with education related to one of the most common and severe adverse effects of cyclosporine, which is
A) hyperthyroidism. B) nephrotoxicity. C) gastritis. D) cardiac effects.
A client is prescribed donepezil. The nurse would assess the client for which of the following as a possible adverse reaction? Select all that apply
A) Anorexia B) Dizziness C) Headache D) Constipation E) Bradycardia
The nurse is providing care for a patient who is receiving a blood transfusion. Pre-transfusion vital signs were blood pressure (BP), 144/78 mm Hg; temperature (T), 98.4°F; pulse (P), 86; respirations (R), 14
Now, approximately an hour after the transfusion was initiated, the patient's vital signs are BP, 168/92 mm Hg; P, 98; R, 20. Next, the nurse should 1. Record the vital signs. 2. Listen to the patient's breath sounds. 3. Notify the physician. 4. Slow the transfusion rate.