The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm
Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders, which order is of the highest priority? a. Lasix 20 mg intravenous push as needed
b. 500 mL albumin intravenous infusion
c. Decadron 10 mg intravenous push
d. Dilantin 50 mg intravenous push
B
To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications.
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The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?
A. Place a towel roll under the client's neck or shoulder. B. Keep the client in a supine position without the use of pillows. C. Have the client turn the head from side to side 90 degrees every hour while awake. D. Keep the client in a semi-Fowler's position and actively raise the arms above the head every hour while awake.
Which assessment is categorized as objective data?
a. A list of herbal supplements regularly used b. Lab values associated with drugs the patient is taking c. The ages and relationship to the patient of all household members d. Usual dietary patterns and intake
A student nurse asks, "Does ethnocentrism have any negative consequences?" The most accurate reply is based on the understanding that
a. discrimination is the basis for ethnocentrism and prejudice. b. ethnocentrism may give rise to prejudice, which may result in discrimination. c. prejudice has no relationship to ethnocentrism and discrimination. d. ethnocentrism has only positive consequences associated with ethnic pride.
The nurse is emulating the characteristics of caring, as described by Mayeroff. Which action demonstrates knowing, in relationship to caring?
1. Seeing that a client is withdrawn and sullen, and spending extra time when providing cares or treatments 2. Understanding the reason a client's lab values are elevated 3. Seeing the connection between the pathophysiology of the cardiac condition and treatment and giving the rationale for certain medications when the client asks 4. Getting an extra blanket when the client says he is cold