On the first postoperative day following a total thyroidectomy, the nurse assesses signs that indicate a developing "thyroid storm," which are: (Select all that apply.)
a. rising temperature (over 101° F).
b. pulse dropping below 60.
c. brief attention span.
d. apprehension and restlessness.
e. respirations below 14.
A, C, D
Rising temperature, pulse, and respirations are the first signs.
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A woman with a history of heart failure is in labor and has the following vital signs: blood pressure: 100/58 mm Hg, pulse: 120 beats/minute, respiratory rate: 36 breaths/minute, oxygen saturation: 88%. Which action should the nurse perform first?
A. Administer oxygen at 10 L/min per rebreather mask. B. Call the health-care provider to report the results. C. Document the findings in the patient's chart. D. Increase the woman's IV infusion to 150 mL/hour.
After receiving numerous doses of a narcotic for pain, the client seems to require the medication more often and states that it doesn't seem to be working now
The nurse understands that this probably represents the client has developed ____ to the medication or dose a. tolerance c. cognitive dependence b. psychological dependence d. synergism
On the basis of a nutritional screening, the nurse has developed a care plan that includes a diagnosis of imbalanced nutrition: less than body requirements. What would be a realistic goal for this client?
1. Increase weight by one pound per week 2. Decrease physical activity to 2 hours per week 3. Increase fat in the diet 4. Replace sweets with high-protein foods
The nurse is performing tuberculin testing on a patient. Which action by the nurse is correct?
a. Insert the needle, bevel up, at a 30-degree angle. b. Massage the area gently after the injection. c. Measure the diameter of the area of erythema when reading the result. d. Use a 25-gauge, 3/8" needle.