The physician order reads "Lopressor (metoprolol) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66 . The nurse does not give the medication and
a. Does not tell the patient what the blood pressure is.
b. Documents only what the blood pressure was.
c. Documents that the medication was not given owing to low blood pressure.
d. Does not need to inform the health care provider that the medication was held.
C
The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider.
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Two brothers played with their cousin. One brother later became quite ill, whereas the other did not. Which of the following provides the best explanation for this occurrence?
a. Difference in length of time exposed b. Difference in how actively the children played c. Difference in genetic inheritance between the two brothers d. Difference in lifestyle between the two brothers
A nurse is discussing precautions used for patients with known or suspected serious illness transmitted by airborne droplet nuclei. For which disease process would airborne precautions be implemented?
A) Scabies B) Measles C) Pertussis D) Impetigo
Which intervention is essential for the nurse to perform for a client who had a total abdominal hysterectomy?
a. Instruct the client on a low-fat diet. b. Monitor for the onset of menopause. c. Assess for problems with intercourse. d. Teach exercises to prevent incontinence.
A client who has just had an IV started in the right cephalic vein tells the nurse that the wrist and the hand below the IV site feel like "pins and needles." Which action by the nurse is best?
a. Document the finding and continue to monitor the IV site. b. Check for the presence of a strong blood return. c. Discontinue the IV and restart it at another site. d. Elevate the extremity above the level of the heart.