A 25-year-old primigravida is at 20 weeks' gestation. The nurse takes her vital signs and notifies the healthcare provider immediately because of which finding?
1. Pulse 88/minute
2. Rhonchi in both bases
3. Temperature 37.4°C (99.3°F)
4. Blood pressure 130/78
2
Rationale 1: The pulse will increase 10–15 beats/minute during pregnancy, with 60–90 beats/minute being the normal range.
Rationale 2: Any adventitious breath sounds are abnormal.
Rationale 3: Temperature norms in pregnancy are slightly higher due to fetal metabolism: 36.2–37.6°C (98–99.6°F).
Rationale 4: A blood pressure lower than 135/85 is considered normal.
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The nurse recognizes which of these persons is at greatest risk for undernutrition?
a. 5-month-old infant b. 50-year-old woman c. 20-year-old college student d. 30-year-old hospital administrator
The client is prepared for shoulder surgery and tells the preoperative nurse that the scar will be invisible after the surgery. Which should the nurse implement next?
1. Tell client that this surgery always leaves a scar. 2. Change consent form to reflect what client says. 3. Inform surgeon that client is not ready for surgery. 4. Confirm procedure and patient identity on consent.
A nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? Select all that apply
a. Bedding should be washed in warm water and dried on a low setting. b. After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo. c. Retreat the hair and scalp with a pediculicide in 7 to 10 days. d. Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks. e. Combs and brushes should be boiled in water for at least 10 minutes.
The GLOBE studies identified a portrait of leader behaviors that almost everyone, in all cultures, would deem exceptional. Which of the following fit into that universally desirable portrait?
a. Integrity b. Self-protective behaviors c. Interpersonal skills d. Charismatic/values orientation