A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?
A. Call the health care provider
B. Check the hourly urine output
C. Check the IV site for infiltration
D. Place the client in a modified Trendelenburg position
Answer: D. Place the client in a modified Trendelenburg position
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The nurse is working the triage, phone answering questions about the radiologic disaster. When in the fallout period of the disaster, which suggestion is most appropriate?
A) Stay with friends and family in an outdoor area with good ventilation. B) Remove all outer garments before entering a house or shelter. C) Use a fan to circulate air from the outdoors to the inside. D) Bring all outdoor pets inside to limit their exposure.
When communicating with a client's physician, the nurse suggests ordering a STAT chest x-ray for a client who is experiencing dyspnea. This is an example of which component of the SBAR format for communicating with the client's physician?
a. Situation b. Assessment c. Background d. Recommendation
The nurse inserts a nasogastric (NG) tube to the measured length. Which method is the best way to confirm placement of the NG tube without an x-ray film?
a. Measure the pH of the gastric aspirate. b. Ask the patient if the tube is comfortable. c. Instill air and listen over the stomach. d. Advance the tube past the measured length.
A terminally ill client realizes that death is near and dwells on past losses. Based on this information, which stage of dying should the nurse identify in the electronic medical record that this client going through?
A) Denial B) Anger C) Bargaining D) Depression