After bathing and repositioning a patient, the nurse notices the following readings on the bedside monitor: PAWP, 20 mm Hg and PAP, 28/12 mm Hg. Assessment notes no changes in patient condition. Which of the following statements would be true?
a. The patient may be having a silent MI.
b. The monitoring system is not functioning properly.
c. The patient is at increased risk for congestive heart failure.
d. The patient has pericardial tamponade.
B
It is physically impossible for the pulmonary artery wedge pressure to be higher than the pulmonary artery pressure. Because these readings show this situation, the monitoring system needs troubleshooting.
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The nurse has just taken a continuing education class on assertive communication techniques. Which response best demonstrates that the nurse understands assertive behavior?
1. "No, I cannot work for you on Sunday." 2. "Yes, they always ignore staff requests." 3. "It would be selfish to ask for time off." 4. "I will demand a change in my schedule."
What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?
A. The burn is full thickness rather than partial thickness. B. The client is unable to fully pronate and supinate the extremity. C. Capillary refill is slow in the digits and the distal pulse is absent. D. The client cannot distinguish the sensation of sharp versus dull in the extremity.
An older adult patient has an elevated prostate-specific antigen (PSA) level. The nurse shares with him that a diagnosis of prostate cancer would be confirmed with an analysis of his
a. alkaline phosphatase level. b. acid phosphatase level. c. serum amylase level. d. uric acid level.
The nurse is evaluating care given to the client with urinary calculi and, anticipating discharge, is providing instruction to the client
Which of the following would the nurse teach the client to prevent further complications of urinary calculi prior to discharge? 1. Refrain from driving while taking pain medications 2. Signs and symptoms of impending urinary tract infection (UTI) 3. Increase fluid intake to 1L/day 4. Maintain a diet high in purines