A 72-year-old patient has just undergone an abdominal aortic aneurysm repair. The patient is pulling at the Foley catheter, nasogastric tube, central line, and abdominal dressing
After applying an extremity restraint the nurse needs to assess which of the following? Select all that apply. A. Vital signs
B. Physician's or health care provider's orders
C. Complaints made by the patient
D. Skin and neurovascular status
B, D
Vital signs are taken routinely with or without restraints. Patients and families are informed before the restraints are applied.
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A nurse is administering an intramuscular vaccination to an infant who has Wiskott-Aldrich syndrome. Because of this syndrome, this infant is at higher risk for:
1. Pain at the injection site. 2. Bleeding at the injection site. 3. Redness and swelling at the injection site. 4. Mild rash at the injection site.
A student nurse asks, "What's the primary purpose of the evaluation phase of the nursing process?" The best response is to
a. establish a time frame for completion of goals. b. determine whether the nurse completed all nursing interventions. c. determine which nurses are eligible for raises or promotion. d. compare actual patient outcomes with desired outcomes.
A nursing board asks the court to stop a nurse from practicing until it investigates allegations that the nurse was providing care while under the influence of alcohol. What is the name of the process that allows this action?
A) Revocation B) Suspension C) Injunctive relief D) Court investigation
The nurse is preparing a client for diagnostic studies requiring the administration of contrast media. Which action by the nurse is the priority in this situation?
1. Obtaining informed consent 2. Obtaining results of lab tests 3. Checking for allergies 4. Checking if routine medications are to be held