A patient is postoperative day 1 from abdominal surgery. The patient is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total 2430 mL. What action by the nurse is most appropriate? a) Assess for edema. b) Document the findings and reassess in 24 hours. c) Discontinue the nasogastric tube suctioning. d) Assess for signs and symptoms of fluid volume deficit.

/in /by

A patient is postoperative day 1 from abdominal surgery. The patient is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total 2430 mL. What action by the nurse is most appropriate?

a) Assess for edema.
b) Document the findings and reassess in 24 hours.
c) Discontinue the nasogastric tube suctioning.
d) Assess for signs and symptoms of fluid volume deficit.

 
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The nurse answers the call light of a male patient. The patient is complaining of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from which of the following? a) The stomach b) The rectum c) The lungs d) The nose

/in /by

The nurse answers the call light of a male patient. The patient is complaining of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from which of the following?

a) The stomach
b) The rectum
c) The lungs
d) The nose

 
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A 66-year-old client presents to the emergency room (ER) complaining of a severe headache and mild nausea for the last 6 hours. Upon assessment, the patient’s BP is 210/120 mm Hg. The patient has a history of HTN for which he takes 1.0 mg clonidine (Catapres) twice daily for. Which of the following questions is most important for the nurse to ask the patient next? a) “Are you having chest pain or shortness of breath?” b) “Have you taken your prescribed Catapres today?” c) “Do you have a dry mouth or nasal congestion?” d) ”Did you take any medication for your headache?”

/in /by

A 66-year-old client presents to the emergency room (ER) complaining of a severe headache and mild nausea for the last 6 hours. Upon assessment, the patient’s BP is 210/120 mm Hg. The patient has a history of HTN for which he takes 1.0 mg clonidine (Catapres) twice daily for. Which of the following questions is most important for the nurse to ask the patient next?

a) “Are you having chest pain or shortness of breath?”
b) “Have you taken your prescribed Catapres today?”
c) “Do you have a dry mouth or nasal congestion?”
d) ”Did you take any medication for your headache?”

 
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A confused patient who fell out of bed because side rails were not used is an example of which type of liability? 1. Felony 2. Battery 3. Assault 4. Negligence

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A confused patient who fell out of bed because side
rails were not used is an example of which type of
liability?
1. Felony
2. Battery
3. Assault
4. Negligence

 
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