The priority assessment the nurse must make during the initial crisis intervention interview is the:
a. need for external controls.
b. adequacy of social supports.
c. patient's perception of the precipitating event.
d. patient's preferred coping mechanism.
A
Safety needs of patients and others are of high priority, so assessment of potential for harm to self or others is of greater importance than the other options.
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A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device?
a. "Provide a bed bath instead of letting the client take a shower." b. "Use sterile technique when changing the dressing." c. "Disconnect the intravenous fluid tubing prior to the client's bath." d. "Use a plastic bag to cover the extremity with the device."
Medication used to increase the level of fetal hemoglobin in the RBCs and reduce the concentration of sickle hemoglobin is known as
a. transfusion therapy. c. Kayexalate. b. hydroxyurea. d. oxygen.
You are describing the "time-out" verification procedure to a nursing orientee. Which statement by the orientee indicates a good level of understanding? (Select all that apply.)
a. The time-out is done at the start of every invasive procedure. b. The time-out prevents wrong site errors. c. The time-out prevents wrong patient er-rors. d. The time-out is done by the surgeon. e. The time-out is required by The Joint Commission (TJC).
The nurse caring for an extremely withdrawn patient with depression wants to assist her to become more interactive. The best approach would be to say:
a. "I know you'll feel better if you leave your room." b. "You look so gloomy sitting here all by yourself." c. "Let's explore how it feels to sit alone here all day and feel sad." d. "I need another person for a card game and I'd like you to be my partner."