Which of the following would be an appropriate intervention when caring for a client experiencing sensory overload?
a. Provide explanation of all procedures prior to implementation.
b. Keep bright lights and the television on in the client's room to help orient her.
c. Work as quickly as possible when performing tasks and procedures so the client has more time to rest.
d. Encourage as many visitors as possible so the client does not feel lonely.
ANS: A
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A nurse is assessing a 6-month-old baby with volvulus. The infant's vital signs are as follows: pulse: 118 beats/minute; blood pressure: 78/54 mm Hg; respirations: 42 breaths/minute. What action by the nurse is most appropriate?
A. Assess the infant's abdomen and skin. B. Document the findings in the baby's chart. C. Increase the rate of IV fluid administration. D. Notify the health-care provider immediately.
A patient has a blood serum drug level of 50 units/mL. The drug's half-life is 1 hour. If concentrations above 25 units/mL are toxic and no more of the drug is given, how long will it take for the blood level to reach the nontoxic range?
A) 30 minutes B) 1 hour C) 2 hours D) 3 hours
The nurse caring for a client with cervical cancer reads on her chart that the cancer extends to the pelvic wall and involves the lower one-third of the vagina. What stage of cervical cancer is this woman manifesting?
A) Stage I B) Stage II C) Stage III D) Stage IV
A nurse who was trained in an acute care setting decides to practice as a home care nurse. Which of the following statements describes one of the major differences between providing client care in the acute care and home care setting?
A) In the home setting, the nurse is in charge of the environment. B) There is more family involvement in the home care setting. C) The hospital environment calls for more flexibility on the nurse's part. D) Hospital nurses provide direct services or supervise those services to assist with activities of daily living (ADLs).