How will you monitor for excessive postoperative blood loss?
What will be an ideal response?
• Observe amount of drainage on the dressing.
• Monitor VS according to orders or the hospital protocol. The protocol might be VS q15min for
1 hour, q30min for 1 hour, then hourly for 4 hours, then every 4 hours. Assess VS for signs of
hemorrhage: decreased blood pressure (BP), increased pulse, and increased respiratory rate;
monitoring the trend over time is especially important.
• Monitor hemoglobin (Hgb) and hematocrit (Hct) levels.
• Send stools to the laboratory forhemoccult testing on stools X 3 . This is important because the
patient is receiving warfarin and enoxaparin.
• Observe for bleeding from other areas, such as nose and gums, and blood in urine and for
excessive bruising.
• Observe for unusual swelling and discoloration of the surgical site.
• Monitor level of consciousness (LOC), restlessness, and pain.
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The nurse, in collaboration with the patient's family, is assigning priorities related to the care of the patient
The nurse explains that when setting priorities it is important to look at the urgency of specific problems. What provides the best framework for prioritizing patient problems? A) Availability of hospital resources B) Family member statements C) Maslow's hierarchy of needs D) Nursing skill
A nurse assigned to a child does not know how to perform a treatment that has been prescribed for the child. What should the nurse's first action be?
a. Delay the treatment until another nurse can do it. b. Make the child's parents aware of the situation. c. Inform the nursing supervisor of the problem. d. Arrange to have the child transferred to another unit.
A nurse is teaching a client about ways to avoid hypocalcemia. Dietary recommendations indicate that vitamin _____ is necessary for calcium absorption
a. A b. B c. D d. E
Grand nursing theories that are based on human needs include all but one of the following. Which is not considered to be a part of needs-based theories?
A) Focus is on the client. B) Client is considered biopsychosocially. C) Individual parts of the client are considered. D) Interventions are prescribed to meet client needs.