A patient has a morphine sulfate patient controlled analgesia (PCA) to control postoperative pain. When the nurse enters the room, the patient complains of pain. The nurse's first response is which of the following?
a. Stop the infusion.
b. Call the physician or health care provider immediately.
c. Ask the patient to describe the pain.
d. Speak to the patient in a calming tone to reduce anxiety.
C
Nurses need to assess the patient first. Next, assess the lines, catheter, and infusion pump. Notify the physician or health care provider or follow protocols should a problem exist. Speaking in a calm voice demonstrates caring behavior.
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In teaching the woman with pregestational diabetes about desired glucose levels, the nurse explains that a normal fasting glucose level, such as before breakfast, is in the range of:
a. 65 to 95 mg/dl. b. 130 to 140 mg/dl. c. 200 mg/dl. d. 55 mg/dl.
A 15-year-old client admitted with severe jaundice is having diagnostic testing. The nursing diagnosis that would have priority is
a. Activity Intolerance related to fatigue b. Deficient Knowledge related to diet modification c. Disturbed Body Image related to yellowing of skin and sclera d. Impaired Skin Integrity related to jaundice
The nurse is caring for a client with diabetic ketoacidosis (DKA) who presents with polyuria, abdominal pain, vomiting, and flushed skin. Which of the following clinical manifestations suggests compensation for the acid?base disorder?
1. The patient exhibits a respiratory rate of 28 with deep inspirations. 2. The patient demonstrates shallow respirations and decreased excursion. 3. The patient has a urine output of 20 ml for the last hour. 4. The patient presents with vomiting.
Death will result if levels of acid and carbon dioxide in the blood become too high
Indicate whether the statement is true or false