MC While taking a radial pulse, you assess that it is irregular with a rate of 72 . Your prep sheet indicates the pulse has been regular since admission. Your first nursing action is to
A. Notify the team leader immediately.
B. Take the radial pulse again in 15 minutes.
C. Document the findings and leave a note for the physician.
D. Take an apical pulse for 1 full minute.
D
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During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. The nurse's priority action is to:
1. Help the fetal head descend faster. 2. Use gravity and manipulation to relieve compression on the cord. 3. Facilitate dilation of the cervix with prostaglandin gel. 4. Prevent head compression.
The client returning to the nursing unit after a total hip replacement has a wedge-shaped pillow strapped between his knees. The client's family asks why this pillow is in place. What is the nurse's best response?
A. "This is to prevent the contact of his knees and reduce the risk for formation of pressure ulcers." B. "This is to prevent the client from inadvertently moving the operative leg too far away from his body." C. "This is to prevent the client from inadvertently moving the operative leg beyond his body's midline." D. "This is to prevent the client from ambulating too early if he should become con-fused."
In the following scenarios, which elders are at higher risk for becoming the victims of abuse? Select all that apply
A) A 62-year-old retiree with chronic kidney disease B) A 65-year-old who is ambulatory with advanced dementia C) An 87-year-old blind retiree who has been living with her daughter for the past fifteen years D) A 76-year-old retiree with metastatic bone cancer E) A 69-year-old retiree who lives alone
The Fair Labor Standards Act (FLSA) of 1938 was passed to set the standards for employment. Included in this act are provisions concerning working overtime. Which statement best describes the provision concerning working overtime?
A) There is a ceiling limit as to the amount of overtime hours that can be worked by any one individual. B) Individuals cannot be dismissed from their job if they decide to decline to work overtime. C) For each hour worked over 40 hours, payroll employees must be paid time and a half the regular pay rate. D) Persons refusing to work overtime can receive sanctions from the employer.