The nurse palpates an older patient's lower legs and notices an indentation of approximately 4 mm left by the fingertips, which disappears in about 10 seconds. The nurse documents this edema as:
A) +1.
B) +2.
C) +3.
D) +4.
B
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A newly licensed nurse is passing medications with a nurse preceptor. Which action taken by the newly licensed nurse would be inappropriate and require the nurse preceptor to intervene?
A) The newly licensed nurse verifies tube placement prior to administering medications. B) The newly licensed nurse checks for known allergies prior to administering medication. C) The newly licensed nurse combines medications with the same active ingredient. D) The newly licensed nurse has a second nurse check the medication order.
The nurse is assessing a patient who is six hours postoperative from coronary artery bypass graft (CABG) surgery. The patient's heart rate is 120, blood pressure is 90/50, urine output is decreased, chest tube output is decreased,
heart sounds are muffled, and peripheral pulses are diminished. What action should the nurse take first? 1. Notify the physician immediately. 2. Recheck vital signs in 15 minutes. 3. Reposition the patient. 4. Increase the intravenous fluids.
A licensed practice nurse (LPN) is working as a staff nurse. What role do the LPNs working as staff nurses play?
A) Work only in long-term care facilities and at client's homes B) Provide direct nursing care to the clients in the health care facility C) Work only as care providers, team members, and communicators D) Supervise the work of charge nurses working in different units
A nursing assistant is performing mask-to-mouth ventilation on a patient. The assistant must remember to do all of the following except
A) seal his or her mouth over the ventilation port. B) watch the patient's chest. C) take a deep breath. D) place the small end of the mask over the bridge of the patient's nose.