What actions do you need to take based on this concern?
What will be an ideal response?
• Call the physician
• Raise the HOB.
• Stay with C.P. and thank her for reporting the change in status to you.
• Closely monitor for wheezing, dyspnea, cardiac arrhythmias, and other signs of hypocalcemia.
• Reassess Chvostek and Trousseau signs.
• Check the patency of the IV line, and prepare for calcium gluconate infusion.
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What are early signs of varicella disease?
a. High fever over 101 ° F b. General malaise c. Increased appetite d. Crusty sores
A nurse notes a 2-mm open shallow ulcer with a red wound bed on the great toe where shoe touched the skin. Which of the following should the nurse document?
A) 2-mm stage II pressure ulcer B) Stage III pressure ulcer on great toe C) 2-mm skin tear with red wound bed D) Red ulcer on the great toe 2 mm in size
The nurse is working with a patient who does not speak English. An interpreter is contacted and brought to the unit to relay information. Which of the following are appropriate interventions when an interpreter is used for patient communication? Select all that apply
A) it is best to use an interpreter whose age, gender, and background fit best with the patient or family B) do not brief the interpreter with information before the face-to-face translation C) during face-to-face translation, be sure to look at the patient and not at the interpreter when speaking D) have the interpreter speak to the patient by starting with, "The nurse says..." E) use short sentences that stop often to allow time for the interpreter to translate F) ask the interpreter to paraphrase or abbreviate what the patient says
The nurse examines a client and assesses a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which area?
A) Mental status B) Hearing C) Neurologic status D) Vision