The nurse is caring for a patient who has received a liver transplant. The patient's blood pressure is dropping and there is increased bloody drainage from the Jackson-Pratt drains at the abdominal incision
What is the most important nursing action?
A) Administer intravenous fluid bolus.
B) Continue close observation and monitoring.
C) Notify the surgeon.
D) Milk the Jackson-Pratt drainage tubes.
C
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The nurse is reviewing a client's history and physical information. The medical record notes a protrusion into the posterior vaginal wall. Based on this data, which condition does the nurse suspect?
1. Ovarian cyst. 2. Bartholin gland infection. 3. Cystocele. 4. Rectocele.
The informatics nurse reviews the implementation plan for the new health information system. When should the nurse expect the strategic planning process to end?
A) System implementation. B) Review of lessons learned. C) Purchase of the equipment. D) Hiring of the IT support staff.
The spouse of a patient recently diagnosed with terminal cancer has voiced concerns about her husband's continual denial of his disease. When planning a response to her, which of the following should the nurse consider?
1. There is a limited amount of time left in the patient's life so the denial must be rapidly worked through. 2. It will be helpful to plan an intervention to force the patient to acknowledge his disease. 3. It may be helpful for the patient's emotional state at this time to be in a state of denial. 4. Denial is abnormal and the patient needs to have a consultation with a therapist.
During administration of eye drops, the nurse should teach the client to prevent systemic absorption of the drug by performing which action?
a. Use the ointment form of the drug. b. Apply the drug directly on the cornea. c. Have the client look straight ahead. d. Gently press on the lacrimal duct.