A nurse utilizes the nursing process to take care of clients in a busy medical-surgical unit in a suburban hospital
The nurse uses bedside and hand-held monitors to collect a variety of information, including blood glucose level, clotting time, electrocardiograph rhythm, cardiac output, blood pressure, oxygen saturation of hemoglobin, and temperature. For which part of the nursing process does the nurse use the above technology?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
A
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A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action?
a. Document as a stage I pressure ulcer and apply a transparent dressing. b. Document as a stage II pressure ulcer and start wet-to-dry gauze treatments. c. Document as a stage III pressure ulcer and start antibiotic therapy. d. Document as a stage IV pressure ulcer and prepare the client for débridement.
A young adult patient comes to the emergency department with severe chest pain and agitation. Which action should the nurse take first?
a. Give naloxone (Narcan) IV. b. Ask about any use of stimulant drugs. c. Assess orientation to person, place, and time. d. Check blood pressure, pulse, and respirations.
A 63-year-old male patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the physician?
a. Cloudy appearing urine b. Hypotonic bowel sounds c. Heart rate 102 beats/minute d. Continuous stoma drainage
A patient with chronic liver disease is prescribed dexlansoprazole (Kapidex). What should the nurse instruct the patient about this medication?
a. Take the entire dose of medication whole. b. Crush the medication and sprinkle in water. c. Take this medication with a full glass of milk. d. Take half the medication with breakfast and the other half with dinner.