The nurse, assessing a patient with multiple injuries, is concerned about the patient's ability to maintain adequate oxygenation because of which of the following assessment findings?
1. thoracic injury from steering wheel compression
2. cervical neck injury and slight concussion
3. hypoactive bowel sounds
4. hemoglobin level 14 mg/dL
2
Rationale: Since the respiratory system requires constant input from the nervous system, the assessment findings of a cervical neck injury and slight concussion would be the ones that concern the nurse about the patient's ability to maintain adequate oxygenation. Thoracic injury and hypoactive bowel sounds would not necessarily impact the patient's ability to maintain adequate oxygenation. A hemoglobin level of 14 mg/dL would be sufficient for oxygenation to the tissues and would not cause the nurse concern.
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A nurse moving from one state to another knows that licensure requirements fall under which jurisdiction?
1. The state 2. The federal government 3. The National League for Nursing 4. The International Council of Nurses
The client is comatose and the healthcare provider orders that the client's temperature is to be taken by the rectal route. The student nurse is assisting the more experienced nurse and volunteers to obtain the client's temperature
Which of the following statements by the student nurse indicate the need for further education? 1. "I will need to turn the client into the prone position.". 2. "The probe for a rectal thermometer is usually red.". 3. "I should insert the thermometer 1.5 to 4 centimeters into the client's anus.". 4. "This is an appropriate way to monitor a client's temperature if they are unable to close the mouth around the oral thermometer.".
Contracture is defined as
A) wasting of muscle tissue. B) inability to move. C) abnormal shortening of a muscle. D) all of the above
The nurse planning care for a client with acute grief will:
1. Advise the client to limit contact with support persons 2. Provide information about the grief process 3. Suggest postponing use of community resources for 6 weeks 4. Encourage dependence on the nurse for support