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To determine whether the client currently is experiencing difficulty, the nurse asks the client about the presence of which early symptom? Rationale: Decreased force in the stream of urine is an early sign of benign prostatic hyperplasia. The stream later becomes weak and dribbling.
The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the nurse to report to the primary health care provider? 1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized Ratio (INR) of 1.3 2.
The nurse instructs the clients to perform the examination: A. At the onset of menstruation B. Every month during ovulation Rationale: The breast self-examination should be performed monthly 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended.
The nurse notes that the client's chart contains the following information: blood type AB, Rh-negative; serology-negative; indirect Coombs test-negative; fetal paternity-unknown. The nurse should anticipate taking which of the following actions?
0:3920:00Who do you see first? Patient Prioritization and NCLEX questionsYouTubeStart of suggested clipEnd of suggested clipSo let's say you're looking at a question you want to know who is the priority patient. ThankMoreSo let's say you're looking at a question you want to know who is the priority patient. Thank yourself that they have a chronic situation or is it an acute situation.
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.
Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).
Studies revealed priorities set by nurses include prioritisation between patient groups, patients having specific diseases, the severity of the patient's situation, age, and the perceived good that treatment and care brings to patients.
The purpose of incident reporting is to record an incident, determine its possible cause, document any actions taken, and make it known to stakeholders. An incident report can be used in the investigation and analysis of an event.
The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, staff member, or visitor—is injured or involved in a situation with the potential for injury, an incident report is required.
Prioritizing like a proA: Things that need to be addressed now (if you don't, the patient will suffer serious harm)B: Things that need to be addressed soon (you definitely can't ignore these issues)C: Things that need to be addressed today (not doing them would delay discharge or hinder routine care)More items...•
Any nursing diagnoses that directly relate to survival or a threat to the patient's mortality should be prioritized first. This may be related to the patient's access to air, water, or food, defined as the necessities of survival.
Priority setting can be defined as the ordering of nursing problems using notions of urgency and/or importance, in order to establish a preferential order for nursing actions.
The first-level priority problems are health issues that are life-threatening and require immediate attention. These are health problems associated with ABCs; airway, breathing, and circulation, such as establishing an airway, supporting breathing, and addressing sudden perfusion and cardiac issues.
The five priorities focus on: recognising that someone is dying; communicating sensitively with them and their family; involving them in decisions; supporting them and their family; and creating an individual plan of care that includes adequate nutrition and hydration.
Expectations, with reference to healthcare, refer to the anticipation or the belief about what is to be encountered in a consultation or in the healthcare system. It is the mental picture that patients or the public will have of the process of interaction with the system.
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.
The most important thing you do as a nurse is to ensure the safety of your patient and this begins the moment you start taking report with something referred to as safety checks. Now, exactly what this means from hospital to hospital may vary, but I want to give you a broad overview.
Asking questions during the report is a wonderful way to learn and make sure nothing was forgotten. Taking report is a skill and it can be extremely intimidating. Think of yourself as an investigator trying to uncover everything you can about this patient.
A nurse notices that a client who is 1-day postoperative knee replacement surgery has a cool numb foot with a weak peripheral pulse. The nurse pages and asks the health care provider (HCP) to come see the client. The HCP states that the client's foot has been like that since surgery and that there is no need to come.
1. LPN assigned to a client with a gastrointestinal bleed and hypotension who is receiving blood and requires vital sign monitoring every hour . 2. LPN assigned to a newly admitted client with a bowel obstruction who is experiencing severe abdominal pain .
1. 20-year-old college student who reports getting a ringlike, red bull's eye-shaped, itchy leg rash after hiking in the woods 2 days ago . 2. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching .
A nurse reports to the hospital occupational health nurse (OHN) that the nurse was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when test results will show positive or negative for HIV infection for the nurse.
During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report.
A nurse is creating a personalized plan of care for a client being admitted to the medical unit with severe bronchits who reports harsh, nonproductive cough and is currently a smoker. List the nursing interventions in the appropriate order utilizing the nursing process. All options must be used.
A nurse working on an acute care urology unit is assigned to a client who requires hourly urine measurement. The previous two urine measurements have been within normal limits. The next urine measurement is now due, but the nurse is busy and running late with medication administration.
Teach health and safety practices to children and their parents. The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion.
The nurse should ask the person to talk to the family directly. A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as. A mentally incapacitated client is scheduled for surgery.
A prescription has just been received for a 72-year-old client with gastrointestinal hemorrhage to have two blood transfusions. The registered nurse caring for the client is a pediatric nurse temporarily assigned to the unit who has never administered blood before. The best action of the charge nurse is to:
1. A 72-year-old client with diabetes who requires a dressing change for a stasis ulcer. 2. A 42-year-old client with cancer of the bone reporting pain. 3. A 55-year-old client with terminal cancer being transferred to hospice home care. 4.
1) A 2-day old infant who is lying quietly alert with a heart rate of 185. 2) A 1-day-old infant who is crying and has a bulging anterior fontanel. 3) A 12-hour-old infant who is being held, with respirations that are 45 breaths per minute and irregular.