A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately?
a. Blood pressure 110/60
b. Temperature 101.3° F
c. Poor skin turgor and pallor
d. Heart rate of 100 beats/min
ANS: B
A fever should be reported immediately and the blood transfusion stopped. All other assessment findings are expected. Blood is given to elevate blood pressure, improve pallor, and decrease tachycardia.
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The major goal of the NICHE (Nurses Improving Care for Health System Elders) program in-cludes which of the following?
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A nurse is treating the pressure ulcer of an African American patient. How would the nurse assess for deep tissue injury in this patient?
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A recently married 28-year-old client has come to the nurse for his physical assessment
During the assessment, he reveals to the nurse that he is worried about achieving a level of social and civic responsibility, because his current workload does not allow him to do so. What would be the best response by the nurse at this time? A) The nurse should indicate that many persons his age are considering building a family. B) The nurse should discuss hobbies appropriate for his age. C) The nurse should teach the client how he can achieve social and civic responsibility. D) The nurse should recommend that the client ease his current workload.
The nurse is administering a medication to a client that is provided in a capsule form. What is the purpose of placing medicine in this form? Select all answers that apply
A) It is easier to swallow. B) It disguises the taste of the medicine. C) It delays the absorption of the medicine. D) It enhances the absorption of the medicine. E) It protects the stomach mucosa from irritation. F) It allows the medication to be released immediately.