33 hours ago A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first? a. Patient who reports foot pain after hammertoe surgery b. Patient who has not voided 10 … >> Go To The Portal
Which patient should the labor nurse assess first after receiving report? The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? Rationale: The infant or child who is the most unstable should be assessed first.
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.
The nurse is the first person on the scene of a motor vehicle accident. The driver is in the driver's seat unconscious. Which action should the nurse implement first? 1. Stabilize the driver's cervical spine. 2. Do not move the client from the accident. 3. Ensure the driver has a patent airway. 4. Control any external bleeding
The nurse notes the client has shallow breathing and a P 67, R 8, B/P 104/62. Which intervention should the nurse implement? 1. Administer the narcotic pain medication IVP.
The first action that the nurse should take is to a. report the patient's complaint to the surgeon. b. check the chart for preoperative assessment data. c. check the vital signs for indications of hemorrhage.
Begin first with the patient who has the highest priority and progress to the patient who has the lowest priority. A nurse is performing a complete physical assessment of an adolescent.
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.
The most experienced nurse should be assigned to the client who requires teach- ing and evaluation of knowledge for home healthcare, because the client is in the surgery center for less than 1 day.
Which medication is most appropriate for the nurse to assign to the LPN to administer? -The sublingual nitroglycerin to the client who is complaining of chest pain.
Terms in this set (59) In what order should the nurse assess assigned clients following shift report? Place in priority order.
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.
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. The charge nurse of a critical care unit is making assignments for the night shift.
An LPN may delegate tasks such as ambulating or feeding a patient to the CNA. The question of when a nurse should delegate is dependent on many factors. Usually, nurses delegate when they need help to prevent patient care delay.
Which client should the charge nurse on the respiratory unit assign to the graduate nurse who just completed orientation? The client diagnosed with bronchiolitis who has a wheezy cough and rapid breathing.
The Licensed Practical Nurse can also give insulin injections, but it's good to keep in mind that some of these insulin medications can have very quick outcomes, so it is important for the nurse to assess before and after administering it.
Under the supervision of a licensed registered nurse (RN) or physician, the LPN/LVN is accountable for the quality of nursing care he or she provides to patients and utilizing the nursing process, assumes responsibility for planning, implementing, and evaluating nursing care for assigned patients in the ...
Of these levels of nursing, only a nurse practitioner is allowed to perform medical procedures in most states and, unfortunately for those who use LPNs to administer injections, most states recognize injections to be medical procedures. Therefore, LPNs should not be performing injections.
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.
The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure. The nurse analyzes the results of a patient's arterial blood gases (ABGs).
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.
After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion.