A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates
1. A blockage.
2. Shock.
3. Decreased plasma volume.
4. Problems with the heart's electrical conduction system.
ANS: 1
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Mrs. Bedard is a 72-year-old woman who has been admitted to the acute care for elders (ACE) unit due to an exacerbation of chronic obstructive pulmonary disease (COPD). The nurse has conducted a focused respiratory assessment
Which of the following assessment findings should the nurse recognize as being anomalous? A) Tactile fremitus is present. B) The ratio of the anteroposterior diameter of Mrs. Bedard's chest to the lateral diameter is 1:2. C) Thoracic percussion over Mrs. Bedard's lung fields is resonant. D) Mrs. Bedard's resting respiratory rate is 26 breaths per minute.
The nurse assesses a client with pneumonia and notes decreased lung sounds on the left side and decreased lung expansion. What is the nurse's best action?
a. Have the client cough and deep breathe. b. Check oxygen saturation and notify the health care provider. c. Perform an arterial blood gas analysis. d. Increase oxygen flow to 10 L/min.
A patient with a recent spinal cord injury is at risk for complications to the gastrointestinal system. Which nursing intervention is primarily directed at minimizing this risk?
1. Insertion of a nasogastric tube 2. Regular assessment of the patient's bowel sounds 3. Administration of a lansoprazole (Prevacid) 4. Elevating the end of the bed to 35 degrees
The nurse is preparing an infusion of norepinephrine for a patient with acute kidney injury
What are the nurse's responsibilities when providing this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Monitor the blood pressure every 2 to 5 minutes. 2. Monitor changes in MAP. 3. Monitor heart rate and pattern. 4. Infuse through the central line. 5. Infuse through a hand vein.