after receiving report on the following patients, which patient should the nurse assess first?

What is a nurse assessing at an urgent care clinic?

A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?

What is the correct nursing diagnosis for a 78-year-old with chronic heart failure?

During a visit to a 78-yr-old patient with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, a correct nursing diagnosis for the patient is a. activity intolerance related to fatigue.

What does the client’s family tell the nurse about the client?

The client’s family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take? A nurse administered a medication via the wrong route.

What should a nurse on a medical-surgical unit assess?

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy? Verify the client and blood product information with another licensed nurse. A nurse is preparing to administer a blood transfusion to a client.

What does a nurse learn when admitting an 82 year old with acute decompensated heart failure?from quizlet.com

While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a

What is the role of a home health nurse?from quizlet.com

A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care.

What degree does ADHF affect the head of the bed?from quizlet.com

Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees.

What does JVD mean in nursing?from quizlet.com

1. While assessing a 68-yr-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates

What happens to a 67 year old after a myocardial infarction?from quizlet.com

Following an acute myocardial infarction, a previously healthy 67-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about

What is the best treatment for heart failure?from quizlet.com

The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction below 40% should receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.

Is ACE inhibitor a first line measure?from quizlet.com

ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol ...

How to provide patient safety?

Another way to provide patient safety is through hand hygiene, especially when working with a patient’s IV line. Be sure to wash your hands, wear gloves, and scrub the hub for 15 seconds prior to connecting tubing to prevent central line associated bloodstream infection. Hospital falls are another safety concern.

What is the responsibility of a RN?

Rather, it is the RN’s responsibility, as well as her/his right, to confirm and ask the patient if they understand what is going to happen to them. Thus, look to see if the patient looks confused, or ask if they have any questions before signing consent as a witness.

What is the NCLEX test?

What's tested on the NCLEX: Safe and Effective Care Environment. The NCLEX-RN exam is designed to challenge your ability critically think through information provided to make safe and sound judgements about patient care. If you are a student that focuses primarily on memorizing every drug, every nursing intervention, and every disease process, ...

What is the first subcategory of the Safe and Effective Care Environment?

The first subcategory of the Safe and Effective Care Environment client need is Management of Care , which accounts for about 20 percent of the questions on the exam. Nursing actions that are covered in this subcategory include:

What is the role of RN in healthcare?

The RN is the health care professional spending a majority of time with the patient. Thus, it’s also the person who knows the patient best among the healthcare team. In advocating for the patient and managing their care effectively, it is the RN’s responsibility to make sure informed consent is obtained before procedures.

Why is confidentiality important in healthcare?

Keep information confidential. Confidentiality is an important part of a safe and effective care environment . This includes asking a patient if he/she is comfortable answering questions and talking about their health care with family members in the room.

Do you need to recall for nclex?

The truth is that you do not need to rely on recall to correctly answer the NCLEX -RN questions. However, you must be comfortable in your knowledge of the basic components of nursing, especially when it’s concerning the focus areas of: prioritization, delegation, effective communication, medication administration, nursing scope of practice, and the nursing process.

What is the purpose of a nurse in an emergency department?

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.

What is a nurse caring for?

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?

What is a nurse teaching self administration?

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?

What is a nurse manager?

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?