A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?
a. Avoid venipunctures.
b. Notify the patient's physician.
c. Apply sterile dressings to the sites.
d. Give prescribed proton-pump inhibitors.
ANS: B
The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.
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When planning client care, which folk belief that may affect health-care practices should a nurse identify as characteristic of the Latino American culture?
1. The root doctor is often the first contact made when illness is encountered. 2. The yin and yang practitioner is often the first contact made when illness is encountered. 3. The shaman is often the first contact made when illness is encountered. 4. The curandero is often the first contact made when illness is encountered.
A client with asthma is receiving metoprolol (Lopressor), a beta blocker for hypertension. The client asks if metoprolol will affect her asthma. What is the best response from the nurse?
a. "Metoprolol may cause bronchoconstriction, and is questionable if it will help decrease blood pressure." b. "Metoprolol decreases pulse rate and thus blood pressure, but it should not have an effect on the bronchioles." c. "Metoprolol causes bronchodilation and increased pulse rate, so refuse the drug." d. "I'll inform the healthcare provider that you should not take metoprolol."
A nurse is caring for a patient with a pneumothorax and a newly placed right-sided anterior chest tube connected to dry suction. The nurse notes bubbles in the middle chamber. What should the nurse should conclude?
1. This is expected with a pneumothorax and will not be seen once the pneumothorax has resolved. 2. This indicates an air leak; the nurse should examine and secure all connections with tape. 3. This indicates a malfunction in the suction setup; the nurse should stop the suction and notify the physician. 4. This is expected with all chest tubes and indicates that the suction is functioning properly.
People with borderline personality disorder are usually very
A. sad and depressed. B. manipulative. C. energetic and happy. D. overweight.