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The nurse is assessing clients in an out-
.
patient clinic. Which of the following signs
exhibited by a client would lead the nurse
to suspect the client has an increased
blood pressure?
Diminished femoral pulse and
cyanosis
Hot dry skin and thirst
Rash and itching
Headache and dizziness
Step by step
Solved in 2 steps
- If the patient was given amlodipine and metoprolol, which of the following would likely be true? The patient would likely experience an increase in HR The patient may have a decreased blood pressure The patient may experience significant tachycardia The patient may experience hypokalemiaThe nurse is working on a busy medical-surgical acute care unit. Which of thefollowing assessment findings should thenurse report to the healthcare provider? A drop in blood pressure from120/80 to 90/50 withlightheadedness in a client gettingout of bed post-operatively A blood pressure of 110/60 in aclient on antihypertensivemedications who is asymptomatic A decrease in temperature from101F to 99F one hour after anantipyretic A respiratory rate of 22 breaths perminute and a pulse oximetryreading of 94% in a client withasthmaAn older resident who is disoriented likes to wander thehalls of his long-term care facility. Which action would bemost appropriate for the nurse to use as an alternative torestraints?a. Sitting him in a geriatric chair near the nurses’ stationb. Using the sheets to secure him snugly in his bedc. Keeping the bed in the high positiond. Identifying his door with his picture and a balloon
- A nurse is assessing infants in the NICU for fluid balancestatus. Which nursing action would the nurse depend on asthe most reliable indicator of a patient’s fluid balance status?a. Recording intake and outputb. Testing skin turgorc. Reviewing the complete blood countd. Measuring weight dailyThe nurse is assessing the respirations ola client with chronic obstructivepulmonary disease (COPD). What is therationale for the nurse to assess therespiratory rate without the client beingaware of it? It is more efficient for the nurse todo so because it takes less time Client awareness might alter therespiratory rate or pattern The client might suppressKussmaul's respirations if awarethe respirations are being counted It allows for observation forrespiratory distress, tachypnea, ororthopneaWhen assessing a patient receiving a continuous opioid infu-sion, the nurse immediately notifies the physician when the patient has:a. A respiratory rate of 10/min with normal depthb. A sedation level of 4c. Mild confusiond. Reported constipation
- Which nursing actions would be most appropriate for ensuring patient safety with a medication that has a low therapeutic index? Monitoring vital signs Monitoring a patient’s urine output Monitoring serum peak and trough levels Maintaining strict-isolation precautionsA physician orders a pain medication for a postoperativepatient that is a PRN order. When would the nurse administerthis medication?a. A single dose during the postoperative periodb. Doses administered as needed for pain reliefc. One dose administered immediatelyd. Doses routinely administered as a standing orderA nurse is monitoring a patient who is receiving an IVinfusion of normal saline. The patient is apprehensive andpresents with a pounding headache, rapid pulse rate, chills,and dyspnea. What would be the nurse’s priority interventionrelated to these symptoms?a. Discontinue the infusion immediately, monitor vitalsigns, and report findings to primary care providerimmediately.b. Slow the rate of infusion, notify the primary care providerimmediately and monitor vital signs.c. Pinch off the catheter or secure the system to prevent entryof air, place the patient in the Trendelenburg position, andcall for assistance.d. Discontinue the infusion immediately, apply warm, moistcompresses to the site, and restart the IV at another site.