a body temperature of 104.2°F heart rate of 116 and blood pressure of 78/52 heart rate of 49 and blood pressure of 152/90 heart rate of 120 and respiratory rate of 9 breaths per minute blood pressure of 82/48 and respiratory rate of 26 breaths per minute
The nurse is caring for a client who just returned from a total hip arthroplasty. A student nurse is helping provide care for this client. Which action by the student nurse requires intervention by the nurse?
The student nurse floats the client’s heels with a pillow. The student nurse positions the client with the legs adducted. The student nurse applies the sequential compression device (SCD) per orders. The student nurse encourages deep breathing and incentive spirometer use every 2 hours.
The nurse is assessing a client with a stage 3 pressure ulcer. Which finding is consistent with this type of pressure ulcer?
Eschar is present on at least part of the wound. Full-thickness skin loss is present with undermining. Partial-thickness skin loss of the epidermis is present. The area is red and does not blanch with external pressure.
The nurse is assessing a client with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which finding would be expected for this client?
hypoxemia and hypocarbia hyperoxemia and hypocarbia hypoxemia and hypercarbia hyperoxemia and hypercarbia
The nurse is caring for a client with seizure disorder. Which statement regarding seizure precautions is correct?
Padded tongue blades should be at the bedside. Oxygen and suctioning should be at the bedside. Padding bed rails with blankets can help prevent injury. Restraint mitts will help keep the client from removing tubes or IVs.
The nurse is training persons enrolled at a community center information session on administering naloxone (Narcan) to opioid overdose victims. Which information should the nurse include when teaching this group?
is administered by subcutaneous injection in the abdomen, thigh, or arm works instantly lasts 30 minutes can be administered by lay persons, provided they have had training
The ED nurse has admitted a client with suspected overdose of tricyclic antidepressants. Which signs and symptoms does the nurse expect to find in this client?
confusion dry mouth bradycardia dysrhythmias constricted pupils flushing of the skin
The clinic nurse is seeing a client who is taking duloxetine hydrochloride. When updating the client’s medical history, for which condition mentioned by the client would the nurse notify the health care provider?
recent worsening of insomnia unplanned weight loss of 6 pounds uncontrolled narrow-angle glaucoma removal of a benign skin cancer on the leg
The nurse is educating a client about MAOI and diet. Which dietary selection by the client indicates that the nurse’s teaching was effective?
egg-white omelet with a cup of yogurt baked chicken breast with green beans scrambled eggs with sausage and toast hot dog with sauerkraut, beans, and a fruit cup
The mental health unit nurse is precepting a student nurse. Together they are caring for a client with schizophrenia. The nurse asks the student nurse to select the atypical antipsychotic from the client’s medication list. The nurse anticipates the student nurse to select which medication?
loxapine thioridazine risperidone haloperidol