29 hours ago · 28-The nurse has just received shift report. Which client should be seen first? 1. Client 1 day post-op abdominal aortic aneurysm (AAA) repair who has hypoactive bowel sounds in all 4 quadrants 2. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale 3. Client with a deep venous thrombosis (DVT) who is up … >> Go To The Portal
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN? a. Providing postmortem care for a client b.
The nurse returns in one hour and assesses the patient. Which ethical principal has guided this action? A nurse turns a patient every 2 hours to prevent pressure ulcers, even though turning the patient is uncomfortable. Which ethical principal guides this action?
Which client should the nurse assess first? 1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. 2. The client with a C-6 spinal cord injury who has autonomic dysreflexia.
A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider.
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.
Nurse triage is needed in a number of situations, including within the emergency department. The nurse must assess which client is at the highest risk of being in a life-threatening situation. The first client who must be assessed is the one who has a situation that threatens the airway, breathing, or circulation.
Who Can/Should file a complaint with the Board of Registered Nursing?gross negligence or incompetence.unprofessional conduct.license application fraud.misrepresentation.substance abuse.mental illness.unlicensed activity.
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.
Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries.
Once the "minor" injuries are out of the area, responders should begin to move and triage patients with the RPM acronym; respirations, perfusion, and mental status.
A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.
Once a complaint hits their desk, the board has to determine if the facts as stated in the complaint are a violation of the laws that govern a nurse's practice. If so, an investigation is initiated, and the nurse may respond to the allegations. The board then resolves the complaint. It may or may not require a hearing.
Emergency actions usually take the form of a summary suspension of a nurse's license. The general standard for this action is clear and convincing evidence that continued practice by the nurse would present a danger of immediate and serious harm to the public. This action may be revised after the full investigation.
Terms in this set (33)accept.refuse.refuse and request peer review (if disciplined)(301.352)accept and file safe harbor(303.005)
It is not only important for the nurse but for the patient as well. Nursing report is given at the end of the nurses shift to another nurse that will be taking over care for that particular patient.
If you are required to give report outside of a patient’s room try to keep your voice down so other patients and family members can not hear. Most nurses use the SBAR tool as a guide to help them give report, which is highly recommended.
SBAR stands for S ituation, B ackground, A ssessment, and R ecommendation.