When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data
Which data indicate the need for immediate action by the nurse?
a. Heart rate 102 beats/min
b. Pedal pulses 1+ bilaterally
c. Blood pressure 103/54 mm Hg
d. Chest pain level 7 on a 0 to 10 point scale
ANS: D
The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.
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An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care?
A) Monitor serum sodium levels. B) Assess postural blood pressures. C) Monitor serum creatinine levels. D) Monitor blood pressure every 2 hours.
The nurse is caring for a 14-year-old child with disseminated intravascular coagulation (DIC). What clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Petechiae b. Chronic diarrhea c. Hepatosplenomegaly d. Bleeding from openings in the skin e. Hypotension f. Purpura
What anal or rectal disorder is this patient most likely to have?
A 75-year-old retired construction worker comes to your clinic, complaining of bright red blood in the toilet for the last several months. He has no pain with defecation but has occasional constipation. He states he eats a healthy diet with fruits and vegetables and walks 2 miles a day. He has had a 10-pound weight loss over the last 3 months. He denies fever or night sweats. His medical history includes high blood pressure, coronary artery disease, and arthritis. He has also had an appendectomy. He smoked for 40 years, two packs a day, but quit 15 years ago. He used to drink alcohol but doesn't now. His father died in his 60s of a heart attack and his mother had breast cancer in her 70s. On examination he appears his stated age and sits comfortably on the examining table. His blood pressure is 150/85 and his pulse is 88. He is afebrile. His cardiac, lung, and abdominal examinations are normal. Visualization of the anus shows no erythema, masses, or inflammation. Digital rectal examination elicits an irregular, firm mass on the posterior side of the rectum. After you remove your finger you notice frank blood on your glove. A) Anal fissure B) Internal hemorrhoid C) Prostate cancer D) Anorectal cancer
There are characteristics and a normal sequence of human growth and development. The nurse sees a 2-month-old child in the pediatrician's office. This is the first child for a new mother
One day after the child was born, the mother asks the nurse to describe what the expectations are for the child during the first 3 months. Based on the mother's question to the nurse, what would be the best explanation by the nurse about the major level of cognitive development for a 2-month-old child? A) Develop preferred sleeping position and cry to signal needs B) Laugh, squeal, look at objects for several seconds and reach for and grasp objects C) Smile, babble, follow lights, and react to sounds D) Develop social smile, respond to pleasurable interactions such as looking at the mother's face