A graduate nurse is working for a diabetes unit. The nurse manager has prepared a very thorough orientation, which includes check-offs for taking vital signs
The nurse manager has informed the graduate nurse that their hospital has adopted the Joint Commission's pain standard and that they will be assessing five vital signs. The graduate nurse knows that the fifth vital sign is which of the following? a. Arterial blood gasses
b. Blood sugar
c. Blood pressure
d. Pain
D
National and international organizations have made efforts to correct this problem. The Joint Commission (2013) has a pain standard for health care workers to assess all patients for pain on a regular basis. Many health care institutions have adopted this standard by recommending that pain be assessed as the "fifth vital sign."
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Nurses must be able to clearly articulate at least four dimensions of nursing to any audience or stakeholder. One of these four dimensions includes:
a. the educational level of the nurse b. what nursing is c. how the nursing shortage affects nursing d. holistic care
The nurse is checking results of a neurologic assessment on a client. Abnormal results to testing of the abducens nerve indicate the client could have difficulty with:
1. taste sensation. 2. peripheral vision. 3. adequate tear production 4. chewing food properly.
When planning meaningful stimulation for a client with sensory deprivation, it is most important that the nurse:
a. provide a variety of stimuli so the client will not become bored. b. include visual stimuli because that is the most important sense for most people. c. determine whether the deprivation is due to inadequate stimuli or the inability to receive or process stimuli. d. only to stimulate the client if there is a physician's order to do so.
The nurse is caring for a patient who has invasive hemodynamic monitoring. What is the nurse's highest priority of care for this patient?
1. Prevent infection at the catheter site by changing the dressing as prescribed. 2. Set alarm limits and turn monitor alarms on. 3. Explain to family members why the monitoring is in use. 4. Coil IV tubing on the bed.