Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance. How should the nurse respond?
a. Initiate intravenous (IV) therapy.
b. Order blood for transfusions.
c. Remove and reapply any dressings.
d. Monitor vital signs every 15 minutes.
D
Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure). IV therapy and blood transfusions require a provider's order. Reinforce the dressing with tape as needed to prevent seepage. If the dressing is saturated, replace only the top layers so as not to disturb any clot formation at the wound site.
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Lisa is a new mother with a two-month-old daughter. Lisa tells the family clinic nurse that she is experiencing a lack of sleep because of infant night feedings and her husband's shift work and overtime
The clinic nurse's best description of this family concern is: A) Coping stress B) Caregiver strain C) Parental maladaptation D) Lack of family support
A nurse is discussing storage of breast milk with a mother whose infant is preterm and in the special care unit. What statement would indicate that the mother needs additional teaching?
1. "I can store my breast milk in the refrigerator for 3 months.". 2. "I can store my breast milk in the freezer for 3 months.". 3. "I can store my breast milk at room temperature for 8 hours.". 4. "I can store my breast milk in the refrigerator for 3 to 5 days.".
The client with obsessive-compulsive disorder attempts to control anxiety through ritualistic behaviors. Which of the following interventions by the nurse will increase the client's sense of security?
A) Allowing the client to perform the rituals B) Distracting the client from rituals with other activities C) Encouraging the client to talk about the purpose of the rituals D) Stopping the client from performing the rituals
What other assessment findings would support this complication being present?
What will be an ideal response?