While assessing a client with PIH on magnesium sulfate, the nurse finds that her output for the last hour was 30 mL, her respiratory rate is 20 per minute, her blood pressure is 150/94, and her deep tendon reflexes are absent.
The nurse's next response would be to a. chart her findings c. decrease the magnesium sulfate
b. check for clonus d. notify the physician
Question 2
A baby in the nursery is 18 hours old. Which piece of information would be most essential to pass on to the next shift?
a. Infant has milky discharge from the nipples.
b. Infant has not voided.
c. Infant has polydactyly on each hand.
d. Testes are descended on only one side.
The nurse conducts the health history as the first step in the nursing assessment
The nurse is using Standard Precautions to draw blood.
Client on IV patient-controlled analgesia (PCA).
A client is having an endoscopy performed by a physician who views the upper gastrointestinal intern
Assessing for pit edema
Using small, circular strokes, exfoliate the client’s neck and back.