A nurse is assigned to care for an elderly, confused patient. The patient's son is sitting at the bedside and is watching a loud television program. The nurse needs to complete the respiratory and cardiac assessment and vital signs
What would be the best approach to this situation?
a. Do not say anything. Just do the best you can with the TV on loud.
b. Say: "That TV is too loud for me to do my work. You have to shut it off."
c. Say: "I'll come back after you've finished watching this TV show. Can you use the call bell to let me know when it's over?"
d. Say: "I need a quiet environment while I listen to your mother's chest. I will need to turn the TV down until I'm finished."
ANS: D
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A patient with hypokalemia and heart failure is admitted to the telemetry unit. The nurse is aware that hypokalemia could cause which of the following abnormalities on an electrocardiogram (ECG)?
A) Shortened P-R interval B) Inverted T wave C) Depressed U wave D) Elevated U wave
Which is done after giving medication through a nasogastric tube that is connected to suction?
a. The tube is reconnected to the suction. b. The tube is clamped for 10 minutes and then reconnected to suction. c. The tube is clamped for 30 minutes and then reconnected to suction. d. The tube is left off for 4 hours and then reconnected to suction.
Which of these is an observation that might be made following the administration of a medication?
A. The NG tube is in correct position. B. The IV is patent and there are no signs of inflammation at the site. C. The patient is allergic to penicillin D. The patient's blood pressure decreased as expected
The nurse wants to avoid administering a subcutaneous dose of heparin intramuscularly. Which of the following actions by the nurse will most effectively reduce the chances of IM administration?
a. The nurse should use only a 1-inch needle. b. The nurse should administer the injection in the upper arm. c. The nurse should administer the drug in the abdomen. d. The nurse should administer the injection in the upper thigh.