An older patient requests a small, inflated donut to sit on to relieve pressure. What response by the nurse is most appropriate?
1. "I will obtain the device for you."
2. "Using the donut can cause skin breakdown."
3. "I will need to get an order from the physician."
4. "You will need to wait until discharge and use this at home."
2
Rationale: The use of the device should be avoided because it applies pressure and results in tissue hypoxia.
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The patient asks about his lab test, which showed a high level of TSH and a low level of T4. You explain:
1. "It means that you have an inconsistency in your thyroid tests, and you will need more testing." 2. "I am sorry. You will have to ask your doctor about your lab results. We are not allowed to discuss them." 3. "The TSH is sending a message to your thyroid gland to increase production, but your thyroid isn't doing that." 4. "That means that you will have to go on hormone therapy for the rest of your life."
During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?
a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall
Which action will the nurse take when a patient receiving morphine sulfate via percutaneous coronary angioplasty (PCA) has a shallow, irregular respiratory rate of 6 breaths/min?
a. Elevate the patient's head of bed to facilitate lung expansion. b. Increase the patient's primary intravenous (IV) flow rate. c. Complete the FLACC scale. d. Notify the health care provider and prepare to administer naloxone (Narcan).
The client receives efavirenz (Sustiva) as treatment for acquired immune deficiency syndrome (AIDS). The nurse assesses the client for which serious adverse effect?
1. Cardiac arrest 2. Rash 3. Bone marrow suppression 4. Seizures