17 hours ago Because aspiration is a concern for this patient, the nurse will need to assess the patients vital signs and neurologic status before placing the patient in a supine position. 35. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. >> Go To The Portal
Reporting in front of the patient reassures the patients that they are the priority and nurses are aware of the details in the client condition. Off going nurse will introduce to the patient the oncoming nurse, and assess the patient concerns and the care plan for the day.
The response beginning, "It is important that you be realistic" discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis. Which information will the nurse provide for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a.
d. "I sleep with the head of the bed elevated on 4-inch blocks." ANS: B GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD. A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli.
Assist the patient to the commode every 2 hours during the day A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure?
The nurse should avoid doing painful procedures close to mealtimes, but nausea or vomiting that occurs at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition.
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.
Change-of-Shift Report Should: Include significant objective information about the client's health problems. Proceed in a logical sequence. Include no gossip or personal opinion.
40. Which client would the newborn nursery nurse assess first after receiving shift report? 1. The newborn who has chignon.
An end-of-shift report is a detailed report of a patient's current medical status while under your care as a nurse. When a nurse finishes their shift, they take a few minutes to record the patient's status so that the next nurse has all a patient's information when they take over their care.
WHICH CLIENT SHOULD THE NURSE ASSESS FIRST AFTER MORNING REPORT? Expiratory wheezes should be seen first as may indicate allergic reaction to the contrast.
Change-of-shift report is the time when responsibility and accountability for the care of a patient is transferred from one nurse to another. The communication that ensues during this process is linked to both patient safety and continuity of care giving.
The most experienced nurse should be assigned to the client who requires teaching and evaluation of knowledge for home healthcare, because the client is in the surgery center for less than 1 day.
What instructions should the nurse include when teaching a mother, whose newborn has hyperbilirubinemia, regarding phototherapy and its effects? 1. Breastfeeding should be discontinued until phototherapy is completed.
It can decrease that risk of blood clots that is even more prominent postpartum if a woman has had surgery.” Walking not only lets you test out how well your body feels after delivery — looking at you, vaginal tears — it also eases you back into physical activity without risking major injury.
After the nursing diagnoses and the client's strengths have been identified, planning begins. The planning occurs in three phases: initial, ongoing, and discharge.
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.
Shift reports help improve communication between coworkers or team members, and they ensure proper execution, control and oversight. Managers use shift reports to pass information about proceedings that take place during a specific shift to others.
The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient's safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury.
Taking a nap will interfere with night time sleep. Hourly orientation will not be helpful in a patient with dementia. The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to. a. reorient the patient to time, place, and person.
Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium. The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to.
Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient. Click again to see term 👆.
ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.