The nurse administers sublingual nitroglycerine, a vasodilator, to a patient diagnosed with angina. When the patient's chest pain is not relieved, the nurse prepares to give another nitroglycerine tablet
What is the nurse's priority action prior to administering the next dose of medication?
a. Notify the physician.
b. Elevate the head of the bed.
c. Measure the patient's blood pressure.
d. Place the patient on a cardiorespiratory monitor.
C
It is most important at this time for the nurse to measure the patient's blood pressure because vasodilating medications can result in a significant drop in blood pressure. There would be no reason to notify the physician unless the patient does not respond by the third dose of nitroglycerine. Elevating the head of the bed would be contraindicated, especially if the patient develops hypotension from vasodilation. Although placing the patient on a monitor is indicated, this is not related to administering the patient's medication.
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A client has large dome-shaped lesions filled with clear or yellow fluid. Which toxic agent is likely to be the cause?
A) Vesicant B) Anthrax C) Smallpox D) Chickenpox
The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalizes concerns that the effluent has not become formed and is still liquid green. Which is the nurse's best response?
a. "I will call your health care provider right away because the stool should be semi-solid by now." b. "Your stools will firm up in a few weeks as your body gets used to the ileostomy." c. "You should eat a high-fiber diet to help make the stool bulkier and more solid." d. "You can add buttermilk or yogurt to your diet and avoid carbonated soft drinks."
To effectively manage a client's hallucinations, which therapeutic nursing interventions are most appropriate? Select all that apply
A) Reinforcing the perceptual distortions until the client develops new defenses B) Providing an unstructured environment and assigning the client to a private room C) Supporting the client and reducing anxiety-producing or stimulating situations D) Distracting the client's attention by providing a competing stimulus that is stronger than the hallucination
A staff nurse is told at orientation that the department has a clinical advancement program in place. On what criterion is advancement usually based?
a. Desire for professional growth b. Acceptance of peer feedback c. Advanced application of nursing skills d. Attainment of an advanced degree in nursing