which patient should the nurse assess first after taking change-of-shift report? brain injury

Which response from the nurse discourages the patient from feeling hopeful?

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.

Which patient actions should the nurse plan to control Gerd?

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.

What is the nurse concerned about in a patient with bleeding?

The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume.

What should a nurse do if a patient has nausea and vomiting?

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 patient would the nurse need to assess first after change of shift report?

The nurse has received the shift report. Which client should the nurse assess first? Assess the client for abnormal bleeding.

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.

When triaging emergency room clients which client should the nurse assess first?

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.

Which client should be assigned to the most experienced nurse?

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 client does the nurse assess first after receiving Morning Report?

WHICH CLIENT SHOULD THE NURSE ASSESS FIRST AFTER MORNING REPORT? Expiratory wheezes should be seen first as may indicate allergic reaction to the contrast.

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.

In which order would the nurse care for clients according to priority of care based on triage tag color quizlet?

Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries.

Which patient requires immediate assessment by a triage nurse?

Level-1 patients are critically ill and require immediate physician evaluation and interventions. When considering the need for immediate lifesaving interventions, the triage nurse carefully evaluates the patient's respiratory status and oxygen saturation (SpO2).

Which event would require a nurse to complete and file an incident report?

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.

When making assignments on a medical unit which client should the day shift charge nurse assign to the most experienced nurse?

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.

What are the 4 steps of delegation in nursing?

4 Steps to Nursing DelegationKnow your resources. If you're not sure about which tasks can be delegated, know where to look this information up. ... Build rapport. ... Communicate clearly and respectfully. ... Don't forget to follow up.

What can be assigned to UAP?

UAP's (Unlicensed Assistive Personnel)Assist patients with activities of daily living (ADL's), including: Eating. Bathing. Toileting. ... Perform routine procedures that do not require clinical assessment or critical thinking, such as: Phlebotomy (except for arterial punctures) Take vital signs.