The nurse receives report on a client with active chest pain and a type B aortic dissection noted on CT. The client has an arterial line placed. Which is the most important vital sign to monitor?
a. Temperature
b. Heart rate
c. Respirations
d. Blood pressure
d. Blood pressure
rationale: A client with a dissection will have very strict blood pressure parameters which are usually on the lower side of normal. This is necessary because increased pressure in the vessels increases the bleeding.
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During a performance appraisal, a unit manager praises a staff nurse on the ability to use presencing when caring for terminally ill clients. What did the nurse demonstrate that would exemplify this caring behavior?
Select all that apply. A) Face-to-face discussions with clients B) Instructing clients on how they should perform certain functions C) Sitting quietly with clients D) Taking the time to hold a client's hand E) Guaranteeing quality and safety in care
A hospital that is interested in purchasing IV infusion pumps organizes a group of nurses to evaluate pumps from a variety of vendors. Which type of group has been organized?
1) Short term 2) Ongoing 3) Self-help 4) Work-related social support
The nurse is caring for a patient scheduled to have a magnetic resonance imaging (MRI) study. Which instructions will be included in the teaching? (Select all that apply.)
a. There is only minimal radiation exposure. b. All metal objects, including dental bridges, jewelry, and body piercings, must be removed. c. It will be necessary to be NPO for 4 hours before the procedure. d. A radiopaque medium may be injected during the procedure. e. There may be a tingling sensation in metal alloy filling of the teeth.
What information should the nurse provide a patient regarding the patient's newly created permanent ileostomy?
1. An additional surgery will be required in 2 to 3 months. 2. The stoma will initially produce dark green fecal matter. 3. The stoma should not produce any bloody discharge. 4. Because the condition required a gastroduodenostomy (Billroth I), an ileostomy was also necessary.