When the baby with tetralogy of Fallot becomes irritable and begins to cyanose, the nurse should:
a. Lift the baby to a sitting position
b. Position the baby on the right side with the head elevated
c. Administer oxygen per nasal cannula
d. Place the baby in a knee–chest position
D
The baby should be placed in a knee–chest position. This decreases blood flow to the lower extremities and increases blood flow to the upper body and head. Oxygen is not helpful.
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During a state of low perfusion or low blood pressure, the body may compensate by
A) decreasing heart rate. B) increasing heart rate. C) decreasing stroke volume. D) decreasing preload.
When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm
Which of these should the nurse document as the character of the client's pulse? A) Strong pulse B) Thready pulse C) Rapid pulse D) Bounding pulse
If a client has a positive skin test for tuberculosis (TB), the nurse knows this result indicates that the client:
a. needs further testing b. has been infected with and has formed antibodies against tuberculosis c. has been infected with tuberculosis and requires immediate treatment d. has only been exposed to tuberculosis
A nurse is assessing an older patient for the possible cause of his acute urinary incontinence. Which actions by the nurse are most important? (Select all that apply.)
a. Asking when his last normal bowel movement was b. Monitoring his intake and output c. Determining if he has been screened for prostatic hypertrophy d. Asking him if he awakens during the night to urinate e. Measuring his abdominal girth