The nurse is going to implement a protocol. For which action is the nurse most likely to follow this type of intervention?
a. Preparation of a client for a diagnostic procedure
b. Adjustment of a client's blood pressure medications
c. Administration of IV fluids
d. Management of a client with acute pain
ANS: A
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The nurse is performing post-mortem care for a child of the Hindu faith. In the process of removing medical equipment, intravenous lines, and urinary catheters, the nurse discovers a thread wrapped around the child's neck. The nurse should:
1. Report this finding to social services as a possible act of child abuse. 2. Assume the thread became wrapped around the neck during the unsuccessful resuscitation effort and remove it. 3. Remove the thread for safe keeping and return it to the family with the child's other possessions. 4. Leave the thread in place.
Which of the following would explain the need for a two-part nursing diagnosis?
1. This client has only two nursing diagnoses. 2. The client's problem is caused by two different health issues. 3. The client is at risk for developing a problem. 4. The client has an actual nursing problem.
Time can take on different meanings in different cultural settings
When a nurse is teaching a client about a dressing change that should be done twice a day, and the client is from a culture that is "present-oriented," the nurse should instruct the client to perform the dressing change at which of the following times? A) At times that the client selects B) At 10 AM and 4 PM C) After breakfast and before going to bed D) Whenever the client chooses, as long as it gets done twice daily
When integrating the principles of family-centered care, the nurse would include which of the following?
A) Childbirth is viewed as a procedural event B) Families are unable to make informed choices C) Childbirth results in changes in relationships D) Families require little information to make appropriate decisions