27 hours ago b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse … >> Go To The Portal
A nurse in a pediatric clinic is assessing the reflexes of an infant who is 1 week old. Which of the following images demonstrates the correct procedure to elicit the palmer grasp reflex?
After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done 9 The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a.
During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.
The nurse has received the shift report. Which client should the nurse assess first? Assess the client for abnormal bleeding.
Which of the following clients should the nurse assess first? *When using the acute versus chronic approach to client care, the nurse should place the priority on the client who has a chest tube and has asymmetrical chest movement because this can indicate a tension pneumothorax.
It should include the patient's medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.
When preparing to move or position a patient, the nurse should first:Assemble adequate help to facilitate the change.Assess the patient's ability to assist with the change.Determine the effect of the patient's weight on the change.Decide upon the most effective method to facilitate the change.
WHICH CLIENT SHOULD THE NURSE ASSESS FIRST AFTER MORNING REPORT? Expiratory wheezes should be seen first as may indicate allergic reaction to the contrast.
Terms in this set (59) In what order should the nurse assess assigned clients following shift report? Place in priority order.
Why is the end-of-shift report important? An end-of-shift report is important because it helps the incoming nurse understand how to best care for their patients. They can quickly review a patient's medical history, allergies and the best course of action to take in case of an emergency.
The LPN/LVN is responsible for giving end-of-shift reports. There are several types of reporting systems.
The importance of a change-of-shift report can't be underestimated. Not only does the report provide nurses with an effective and meaningful way to transfer responsibility and accountability of patient care, it helps build team cohesion, enhances shared values, and supports ritualistic functions.
Ensure patient's privacy and dignity. Assess ABCCS/suction/oxygen/safety. Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal. A slider board and full-size sheet or friction-reducing sheet is required for the transfer.
Terms in this set (10) When preparing to move a patient in bed, what will the nurse do first? Assemble adequate help to move the patient. Assess the patient's ability to help with moving.
Be sure the wheels of the bed are locked. Put a garbage bag or plastic slide board between the sheet and draw-sheet, beneath one edge of the patient's torso. Move the patient's legs closer to the edge of the bed. Instruct the patient to cross his or her arms across his or her chest, and explain the move to the patient.
The nurse may need to move the patient to decrease the risk of injury during the seizure. A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work.".
Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity , and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia .
c. "MS is associated with an increased risk for congenital defects."
Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.
a. Insert an oral airway during the seizure to maintain a patent airway.
ANS: B. Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS. A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy.
scheduled routinely, but it should be done only when patient assessment data indicate the need for
The head of the patient's bed should be positioned at 30
b. The RN uses a closed-suction technique to suction the patient.
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease
a. Patient who was extubated in the morning and has a temperature of 101.4° F (38.6° C)
answer. A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client’s family to obtain consent.
A nurse manager is reviewing clients’ rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?
answer. A nurse is caring for a client who has major depressive disorder and has signed an informed consent to receive electroconvulsive therapy (ECT).The client states to the nurse, “I’m not sure about this now. I’m afraid it’s too risky.”. Which of the following responses should the nurse make?
A nurse is teaching self-administration of insulin to a client who has a new prescription for a short-acting and intermediate-acting insulin. Which of the following actions by the client indicates an understanding of the teaching?