Pulsus paradoxus The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension.  A nurse is planning care for a client who is receiving heparin to treat a L leg DVT. Nursing intervention? elevate the leg A nurse is teaching about child safety measures. What statement indicates understanding? avoid sun exposure 10am-2pm A home health nurse is teaching about infection prevention to a cancer pt on chemo. Which statement indicates understanding? "I'll walk short distances throughout the day" A nurse is providing dietary teaching to the parents of a 6 month old. What instructions should the nurse give? introduce new foods over 5-7 days A charge nurse is planning care for a client in mechanical restraints. What interventions? provide a staff member to stay with the client continuously A community health nurse is assisting with the development of a disaster management plan. What nursing responsibility should be included in the disaster response stage? perform a rapid needs assessment A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following requires manager intervention? tells the hospital chaplain a client's diagnosis A nurse is caring for a client that is in labor at 39 weeks gestation. During the second stage of labor, the nurse observes early decelerations on the monitor. What action should the nurse take? continue observing the fetal heart rate A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate staff acceptance, what should the nurse manager do first? provide information about scheduling issues to staff A nurse is planning teaching about allowable foods for a client with uric acid-based urinary calculi formation. What foods should the nurse recommend? Oranges A charge nurse is teaching a newly licensed nurse how to identify true labor. What should the nurse include in the teaching? the cervix transitions to an anterior position A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client can sign the informed consent? the client an accurately describe the procedure |
A nurse is providing teaching to an adolescent following insertion of a tunneled central venous
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