the nurse has received report from a group of patients which patient should the nurse see first

How often does the staff nurse assess neurologic status?

a. The staff nurse assesses neurologic status every hour. b. The staff nurse elevates the head of the bed to 30 degrees. The staff nurse suctions the patient routinely every 2 hours.

What should the staff nurse do before turning the patient?

The staff nurse administers an analgesic before turning the patient. Suctioning increases intracranial pressure and should only be done when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

When is a physical exam indicated in the evaluation of respiratory distress?

When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved.

When is a patient with possible viral meningitis admitted to the nursing unit?

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Restrict oral fluids to 1000 mL/day.

Which client will the nurse assess first after receiving Shift report?

Which client should the nurse on the vascular unit assess first after receiving the shift report? The client with an above the knee amputation who needs a full body lift to get in the wheelchair. The charge nurse of a long-term care facility is making assignments.

Which of the following clients should the nurse assess first?

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.

What did the Joint Commission identify as the primary cause of untoward events that occured in the hospital?

Ineffective communication was identified as the root cause for nearly 70% of all sentinel events reported. The majority of those untoward events involved communication failure.

Which client should the charge nurse assign to the room closest to the nurses station?

Which client should the charge nurse assign to the room closest to the nurses' station? The client with dementia and gastroenteritis presents the greatest safety risk, which includes potential for falls and fluid and electrolyte imbalance.

What is priority in nursing?

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.

In what order should the nurse assess assigned clients following shift Report place in priority order?

Terms in this set (59) In what order should the nurse assess assigned clients following shift report? Place in priority order.

Which of the following would be considered sentinel events that should be reported to the Joint Commission?

A sentinel event is a Patient Safety Event that reaches a patient and results in any of the following:Death.Permanent harm.Severe temporary harm and intervention required to sustain life.

What is the Joint Commission and what does it do?

The Joint Commission accredits and certifies more than 22,000 health care organizations and programs in the United States, including hospitals and health care organizations that provide ambulatory and office-based surgery, behavioral health, home health care, laboratory and nursing care center services.

What is a Joint Commission sentinel event Alert?

Sentinel Event Alert newsletters identify specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences.

Which of the following clients is the most appropriate candidate for receiving outpatient care?

Which of the following clients is the most appropriate candidate for receiving outpatient care? Outpatient services are appropriate for clients who are medically stable but who require diagnostic testing, such as a colonoscopy.

Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float nurse from a general medical unit?

The most appropriate assignment is a stable client, who requires basic pain, peripheral, and neurovascular assessments, which should be familiar to a float nurse from a general medical unit.

Which of the following are incidents about which the nurse should write an incident report?

Occurrences that should be documented on an incident or variance report form include the following: medication error; patient injury; visitor injury; employee injury; condition constituting a safety hazard, such as an unsafe staffing situation or failure to repair reported broken or damaged equipment; failure of ...

Why is it important to determine the least stable patient when planning care for multiple patients?

This patient is most likely to experience physiological problems if the nurse does not address his or her needs. The others are cared for in the priority order determined by their stability and needs. Procrastination and caring for the easiest patient first are not reflective of assessing patient needs and administering patient care management effectively.

What is clinical experience in nursing?

1. During clinical experience, the student nurse is assigned a patient scheduled to undergo numerous treatments. The student decides it is not possible to complete all the needed treatments in the time scheduled for this clinical day. The student nurse consults with the clinical instructor to

How to plan for multiple patient care?

Plan your care of a patient who requires multiple treatments or complex nursing care by determining the priority of the patient's problems or needs so that you can provide care to the patient's highest priority needs first. Delegation would not be the most logical or appropriate choice as the student is not working over anyone. It is not always wise to do the easiest treatment first because difficult treatments may have unexpected outcomes that may challenge time management. Procrastination is never a good approach in managing patient care.

What is the root cause of nearly 70% of sentinel events?

Ineffective communication was identified as the root cause for nearly 70% of all sentinel events reported. The majority of those untoward events involved communication failure. The other options were not identified as the majority of all sentinel events.

What does "delegate" mean in medical terms?

a. delegate one of the patients to someone else.

Can a nurse take a phone order?

The nurse will write the phone order on the chart, and later the health care provider will co-sign the order. The charge nurse does not have to take the phone order ; any licensed nurse can take the phone order.

Why do patients repeat instructions?

Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal.

What does the nurse hear during auscultation?

4. On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?

How to assess for fremitus?

To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as "99." 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. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.

What is Kussmaul respiration?

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. 4.

Do you need to be on bed rest during bronchoscopy?

The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler's position.

What is the best score for a patient to have a motor response?

The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Why should ICP be maintained in the head up position?

The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

What does rhinorrhea mean?

Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

What does it mean when a patient has a clear nasal drainage?

Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

How long after a concussion is a college athlete seen?

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?

What are the vital signs for brain injury?

Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of mostconcern to the nurse?

Should short explanations be given to patients and family members?

Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members' anxiety