The nurse and an unlicensed assistive personnel (UAP)enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?
A. Ask the nursing assistant to complete an incident report
B. Check the client's level of consciousness and vital signs
C. Ask the nursing assistant to assist in getting the client back to bed
D. Contact the unit secretary on the intercom and ask that the client's health care provider be called
Ans: B. Check the client's level of consciousness and vital signs
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The nurse is auscultating the abdomen of a client for vascular sounds with the bell of the stethoscope. The nurse hears a soft, continuous humming sound. Based on this data, the nurse suspects dysfunction with which organ?
1. Stomach. 2. Spleen. 3. Pancreas. 4. Liver.
When assessing a client of African-American descent for jaundice, the nurse should check the:
1. mucous membranes of the mouth. 2. sclera. 3. abdomen. 4. nail beds.
A client diagnosed with open-angle glaucoma asks the nurse what that means. With which of the following responses should the nurse instruct the client?
1. "The eye cannot drain the fluid that it produces.". 2. "It means that the condition occurs within days.". 3. "It is a rare type of glaucoma.". 4. "One of the first signs of it is pain behind the eyes.".
When a diuretic-containing regimen to treat heart failure is used, efficacy is best assessed by:
1. body weight. 2. skin turgor. 3. serum sodium. 4. LV function.