The nurse receives report on an assigned group of patients. Which patient would the nurse assess first?
a. A patient 2 days postoperative who is complaining of pain
b. An older adult patient reported to have increasing lethargy and confusion
c. A newly admitted patient with a serum blood urea nitrogen (BUN) of 32 mg/dL
d. A hypertensive patient complaining of severe midsternum pain
D
The patient with chest pain is at greatest risk of experiencing urgent problems and needs to be evaluated immediately. This does not mean that the nurse will not address the needs of the other patients, but the safety of the hypertensive patient is at risk if the nurse does not see him first.
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An older adult client has experienced a fracture of the arm from a fall. The priority of care for the older client is monitoring for infection because:
1. circulation is reduced. 2. self-care is difficult. 3. the elderly cannot take antibiotics. 4. the elderly have slower reflexes.
A patient returning from surgery complains of incisional pain that is now rated 7 in intensity on the 1-to-10 pain scale. What should the nurse be aware that pain exemplifies?
a. General adaptation syndrome b. Local adaptation syndrome c. Counter-current response d. Neuroendocrine response
A prescriber has ordered a beta1-agonist medication for a patient. A nurse understands that the patient who would most likely benefit from a beta1 agonist would be a patient with which of the following health alterations?
a. Heart failure b. Hypertension c. Asthma d. Glaucoma
The client is taking cetirizine (Zyrtec). The nurse teaches the client to expect which of the following side effects of this medication?
1. Diarrhea 2. Excitability 3. Drowsiness 4. Excess salivation