The burned client on admission is drooling and having difficulty swallowing. What is the nurse's best first action?
A. Assess level of consciousness and pupillary reactions.
B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.
C
Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client's airway is in severe jeopardy and intubation is highly likely to be needed shortly.
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A child is on IV heparin. Which laboratory value does the nurse analyze to determine if the dose is therapeutic?
A. Platelet count B. PT C. PTT D. Red blood cell count
The type of validity that employs primarily judgment in its assessment is:
A) Content B) Concurrent C) Predictive D) Construct
The nurse is admitting an older adult patient to the emergency department (ED) with a change in mental status with recent and remote memory loss
The family tells the nurse the patient's forgetfulness has gotten progressively worse over the past 6 months. Which diagnosis does the nurse anticipate for this patient? 1) Delirium 2) Dementia 3) Depression 4) Anxiety
When donning a sterile gown and gloves using the closed method, it is correct for a nurse to do which of the following? Select all that apply
1. Open the sterile glove wrapper with his or her hands inside the gown sleeves. 2. Tuck the gown cuffs over the gloves. 3. Pick up the sterile gown by the sleeves. 4. Have the glove cuffs cover the gown cuffs. 5. Already have completed a surgical hand scrub.