The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss?
a. all vital signs would expect to be normal with this amount of blood loss.
b. oral temperature of 103°.
c. heart rate 125 beats per minute.
d. systolic blood pressure of 120 mm Hg.
C
As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys.
Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume.
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The nurse is assigned to four patients on the pediatric progressive care unit. After receiving shift report, which patient should the nurse see first?
A. Blood pressure of 88/56 mm Hg in 4-year-old child with heart failure B. Child crying inconsolably after his parents went home C. Pain 5/10 in a child 2 days after cardiac surgery D. Temperature 104.6 °F (40.3 °C) 3 days after dental visit
Which assessment data best indicates to the nurse that an older client is experiencing undernutrition?
1. Body mass index (BMI) of 21 2. Unintentional 3% weight loss over a month 3. Client takes no supplements or vitamins 4. Serum albumin is slightly below normal
A package insert must be dispensed with which of the following?
a. Products containing conjugated estrogen b. Antihistamines c. Antifungal ointments d. OTC first-aid products
T.H. is a 55-year-old man with an 8-month history of progressive muscle weakness. Initially, he tripped over
things and seemed to drop everything. He lost interest in activities because he was always exhausted. He sought medical assistance when his speech became slurred and he started to drool. During the initial evaluation, the physician noted frequent, severe muscle cramps, muscle twitching, and inappropriate, uncontrollable periods of laughter. After undergoing a series of tests, T.H. was diagnosed with amyo trophic lateral sclerosis (ALS). He is upset and bewildered about a disease that he has "never even heard of." You are a home health nurse who is seeing T.H. for the first time. How would you explain ALS to T.H.?