The medical record states that a patient with infective endocarditis has Osler's nodes. The nurse would assess the patient for which finding?
1. Enlarged lymph nodes in the axilla
2. Painful mobile enlargement of the posterior lymph node chain in the neck
3. Painful red or purple lesions on the fingertips or toes
4. Round white spots on the retina
3
Rationale 1: Osler's nodes are not located in the axilla.
Rationale 2: Osler's nodes are not located in the neck.
Rationale 3: Osler's nodes are painful, red or purple, pea-sized lesions found on the fingertips or toes.
Rationale 4: Round white spots on the retina surrounded by hemorrhage are Roth's spots.
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A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.)
a. Consults with other disciplines on client care b. Coordinates discharge planning for home safety c. Participates in comprehensive client rounding d. Routinely asks other disciplines about client progress e. Shows the nursing care plans to other disciplines
Which action should the nurse take to prevent emotional contagion when working with hospitalized depressed clients? Expect the clients to:
1. Be appreciative of a daily one-to-one session. 2. Be open to working on their problems. 3. Show improvement within 24 hours after admission. 4. Be disinterested in a nurse–client relationship.
The nurse and nursing assistant are moving a client who slid down in the chair. What does the nurse encourage the assistant to avoid shearing when moving the client to a higher position in the chair?
A) Tilt the chair back when moving the client. B) Lift the client, do not slide them. C) Encourage the client to slide up without assistance. D) Use a donut device while the client is in the chair.
A patient with a tracheostomy tube has an order for oxygen. Which action by the nurse is appropriate?
a. Apply sterile gloves to connect the oxygen to the tracheostomy tube. b. Check the oxygen tubing frequently to make sure water is present in the tubing. c. Attach the T tube to a humidified oxygen source. d. Monitor the response to oxygen with hourly arterial blood gas levels.