During assessment of a patient with heart failure, the nurse notes that the patient's pulses alternate in strength. What does this assessment indicate to the nurse?
a. Pulsus paradoxus
b. Orthostatic hypotension
c. Hypotension
d. Pulsus alternans
Answer: c. Hypotension
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After completing rounds, the physician prescribes restraints for four patients on the floor. Upon reviewing the orders, the nurse knows that it's inappropriate to apply restraints to which of the following patients?
A) A postlaryngectomy patient attempting to pull out his tracheostomy tube B) A patient in hypovolemic shock trying to pull out his IV catheter C) A patient with urosepsis who rings the call bell often to use the bedside commode D) A paranoid patient who has just tried to commit suicide and is refusing restraints
The nurse is concerned that a school-age child receiving intranasal desmopressin acetate (DDAVP) for enuresis is experiencing an adverse effect of the medication. What did the nurse assess in this patient? (Select all that apply.)
A) Thirst B) Nausea C) Flushing D) Itchy skin E) Headache
Which client position does the nurse prefer for client performance of a peak expiratory flow rate (PER)?
1. Standing 2. Side lying 3. High-Fowler's 4. Reclining in chair
The internal spiral electrode may pick up the maternal heart rate if the baby has died.
a. true b. false