The nurse is caring for a 3-month-old with nasolacrimal duct obstruction. Which intervention would be most appropriate for the nurse to implement?
A) Being careful to prevent spread of infection
B) Teaching the parents how to gently massage the duct
C) Applying hot, moist compresses to the affected eye
D) Referring the child to an ophthalmologist
B
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Listening carefully to the Korotkoff sounds as you deflate the blood pressure cuff, you detect the first sound at 146 . It continues until 94, when the sounds are muffled, and eventually the sounds disappear at 40
Using the recommended method, you record this blood pressure as a. 146/94 c. 146/94/40 b. 146/40 d. 94/40/0
The nurse is preparing to administer the first dose of digoxin (Lanoxin) to a patient and notes that the dose ordered is much higher than the usual recommended dose. Which action will the nurse perform?
a. Administer the dose as ordered. b. Give the dose and monitor for toxicity. c. Hold the dose until reviewing it with the provider. d. Refuse to give the dose.
The nurse monitors the blood glucose levels of a patient being treated with insulin for diabetic ketoacidosis to ensure glucose levels decline at the rate of 50-70 mg/dL/hour because:
1. When blood glucose drops rapidly fluids shift out of the cell, which increases dehydration, causing severe hypovolemic shock. 2. When blood glucose drops rapidly severe damage to the brain results from metabolic alkalosis. 3. A rapid drop in blood glucose can result in hypokalemia, causing life-threatening arrhythmias. 4. A rapid drop in blood glucose can result in formation of thromboses as a result of dehydration.
The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection when what is assessed?
1. Elevated blood pressure. 2. Elevated heart rate. 3. Confusion. 4. Leg pain.