You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention?
A. Notify the physician and complete an incident report.
B. Slow the rate to keep vein open until next bag is due at noon.
C. Obtain a new bag of IV solution to maintain patency of the site.
D. Listen to the patient's lung sounds and assess respiratory status.
Ans: D. Listen to the patient's lung sounds and assess respiratory status.
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A parent of a child suspected of having systemic lupus erythematosus (SLE) asks why so many blood tests are being done. Which response by the nurse is the most appropriate?
A. "Many of these blood tests look for possible organ damage from SLE." B. "SLE is a complicated disorder and is very hard to diagnose." C. "This is a very typical pattern of diagnostic blood tests we usually do." D. "We are also checking for other possible autoimmune diseases."
Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse?
a. Intracranial bleeding b. Encephalitis c. Increasing intracranial pressure d. Meningitis
The continuous administration of mist, or aerosolized water, for the treatment of inflammatory conditions of the airways is a common practice that functions in which manner?
a. Has no proven benefit b. Decreases the viscosity of mucus c. Decreases bronchoconstriction d. Reduces the inflammation of the lower airways
No one can accept his or her death as a natural part of life
Indicate whether the statement is true or false.