A patient is admitted with the diagnosis of sickle-cell crisis. What action should the nurse take first if the patient has a temperature of 102°F, O2 saturation 89%, and severe abdominal pain?
A. Administer oxygen as prescribed.
B. Administer morphine sulfate IM.
C. Assess and document peripheral pulses.
D. Give Tylenol (acetaminophen) grains X (650 mg).
Answer: A
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Ten hours after admission to the ICU following an auto accident, a client begins to exhibit mild tachycardia, irritability, and tremors. Three hours later the client has a grand mal seizure. The staff suspect that the client has:
1. Wernicke's encephalopathy. 2. Korsakoff's syndrome. 3. Undetected internal bleeding. 4. Alcohol withdrawal syndrome.
The nurse has been teaching a client about skin grafting procedures. What statement indicates that the client needs further education about allografts?
a. "Because the graft is my own skin, there is no chance it won't ‘take.'" b. "For a few days after surgery, the donor sites will be painful." c. "I will have some scarring in the area where the skin is removed." d. "I am still at risk for infection after the procedure until the burn heals."
The nurse is planning daily care for two clients. One client needs postoperative teaching. The other client, who has been diagnosed with pneumonia, has a PaCO2 of 85. The nurse decides to assess the client with pneumonia first because:
1. The client needs more care than the client needing postoperative teaching. 2. The nurse can delegate postoperative teaching to an unlicensed assistive person (UAP). 3. The client with pneumonia may be experiencing respiratory distress. 4. The room of the client with pneumonia is closer than that of the client needing postoperative teaching.
For which patient with a bacterial infection does the nurse question a prescription for tetracycline (Tetracon)?
a. 35-year-old patient with AIDS b. 16-year-old patient with severe acne c. 65-year-old patient with hypertension d. 25-year-old patient taking oral contraceptives