A nurse in the intensive care unit is caring for a post-transplantation client. This client's first set of vital signs were temperature 94.4° F, pulse 110 beats/min, respirations ventilated at 20 breaths/min, blood pressure mm Hg
After 2 hours, the vital signs are temperature 98.4° F, pulse 108 beats/min, respirations ventilated at 20 breaths/min, blood pressure mm Hg. Which action by the nurse is most appropriate at this time? a. Anticipate an order for arterial blood gasses (ABGs).
b. Call the physician to report that the client is still tachycardic.
c. Chart the findings and continue to monitor the client.
d. Prepare to administer vasoconstricting agents.
D
Arterial blood pressure, systemic vascular resistance, and cardiac output usually decrease as the client's temperature rises from the hypothermic state seen initially. Additional support measures are often used during this time of instability, such as vasoactive agents. There is no indication for ABGs and the client is probably tachycardic because of the low blood pressure and physiologic stress of the operation. With any intervention, charting and continued observation are required, but it is not the priority action in this situation.
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A nurse working on a medical/surgical unit is preparing to admit an elderly patient from a nursing home. What information does the nurse need to obtain from the family and nursing home during the admission process? Select all that apply
A) Code status B) Goals of treatment C) Current medications D) Past surgeries
To listen therapeutically to the patient, the nurse should try to:
1. concentrate on the patient and not think of responses to the patient while he or she is speaking. 2. determine the cause of the patient's problem while the patient is speaking. 3. ask the patient why he thinks he feels that way. 4. tell the patient that you have had similar experiences.
The law passed in 1991 that requires institutions receiving Medicaid or Medicare funding to provide written information to adult patients regarding their right to make health care decisions is the:
a. Uniform Health Care Information Act. b. Patient Self-Determination Act. c. Patient Bill of Rights. d. Civil Rights Act.