A woman who admits to recent cocaine use is in active labor. Her vital signs are pulse 88, respirations 20 and irregular, and blood pressure 160/90 . She seems lethargic and is sweating profusely. The nurse should:
a. position her on her right side.
b. elevate the head of the bed 90 degrees.
c. maintain the side rails up at all times.
d. keep the overhead lights on for accurate observation.
C
The client who has recently used cocaine is at risk for hypertensive crisis and seizures. Keeping the side rails up contributes to the safety of the client.
You might also like to view...
The nurse is applying a dry gauze dressing to the client's large abrasion. The client asks the nurse why he needs a dressing on it. Appropriate responses include: Standard Text: Select all that apply
1. The dressing will protect the wound from being contaminated by germs. 2. Wounds heal better when they are kept warm, and the dressing will provide insulation. 3. The wound could drain as it heals, and the dressing will absorb the drainage. 4. The wound needs to be kept moist. 5. This will prevent the wound from hemorrhaging.
A patient who is taking rifampin (Rifadin) as part of his treatment for tuberculosis asks about making an appointment for a urologist because his urine is "bright orange." What should the nurse realize this patient is experiencing?
1. a secondary urinary tract infection 2. a common side effect of rifampin therapy 3. the onset of a kidney stone 4. early renal failure
An individual may be at risk for HEV infection if they travel to India and eat
a. curried shrimp. b. fresh fruit salad. c. Tandoori chicken. d. cooked foods from street vendors.
During morning report, the LPN/LVN is assigned a group of patients. Which patient should the LPN/LVN see first?
a. A patient scheduled for magnetic resonance imaging (MRI) due to back pain b. A patient reporting constipation and stomach cramps c. A 2-day postsurgical patient reporting pain at a level of 6 d. A patient with pneumonia who is short of breath and anxious