A patient has a blood pressure of 134/70 per blood pressure cuff and a blood pressure of 90/50 per arterial line. The nurse should:
1. Discontinue the arterial line immediately.
2. Check the level of the transducer and relevel and rezero the system.
3. Do nothing because this is a normal variation between the two methods of measurement.
4. Begin the infusion of a dopamine drip.
2
Rationale 1: The system needs to be assessed first.
Rationale 2: The placement of the transducer is essential for accurate measurement. It must be level with the phlebostatic axis in order for the monitoring system to be accurate.
Rationale 3: This is not a normal variation between the two methods of measurement.
Rationale 4: More information and data are needed before administering medication therapy.
You might also like to view...
A nurse working in the newborn nursery notes that an infant is having frequent episodes of apnea lasting 10–15 seconds without any changes in color or decreases in heart rate. The most appropriate intervention would be to:
1. Call the physician immediately. 2. Continue to observe the infant, and call the physician if the apnea lasts longer than 20 seconds. 3. Suction the infant's mouth and nares. 4. Turn the infant right side down.
The nurse is evaluating outcome goals written by a student for a client diagnosed with alcoholism who is being discharged from a detoxification program. Which outcomes are appropriate for this client?
Select all that apply. A) Follow a 2000-calorie high-carbohydrate diet. B) Sponsor a participant in Alcoholics Anonymous (AA) meetings. C) Obtain at least 6-8 hours of sleep per night. D) Acknowledge the blame that family members must take for codependent behavior. E) Enroll in the Employee Assistance Program (EAP) through his employer.
The nurse joins a professional nursing organization and keeps lists of people met at nursing meetings. This behavior is an example of:
a. networking. b. mentoring. c. referent power. d. client empowerment.
A client admits to being HIV-positive, and that she is at about 16 weeks' gestation. Which statements made by the client indicate an understanding of the plan of care both during the pregnancy and postpartally? Select all that apply
1. "I will take my Zidovudine (ZVD) at the same time every day." 2. "During labor and delivery, I can expect the Zidovudine (ZVD) to be given in my IV." 3. "After delivery, the dose of Zidovudine (ZVD) will be doubled to prevent further infection." 4. "My baby will be started on Zidovudine (ZVD) within 12 hours of delivery." Correct