What other information do you need from the ED nurse before you assume responsibility forthe patient?• What type of pain medicine was given and at what time? What was the patient's response?What is the patient's glucose level?
What did the patient rate the pain before and after the pain medication?
• Check IV fluid and rate, allergies, and code status.
• Document times that any antibiotics or other routine medications were given, and write that time
next to the order so that the pharmacy can institute the proper administration schedule.
• What are the intake and output (I&O) status, the morning labs or procedures, and the pending
consultations?
• Does the patient have any accompanying family members, or have they been contacted?
• A complete system assessment should be given during patient handoff using SBAR (Situation,
Background, Assessment, Recommendation).
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The nurse is instructing a female patient about changes in sexual functioning that may result from the aging process
Which nursing diagnoses would the nurse incorporate into the plan of care for this patient regarding sexual intercourse? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Risk for Injury 2. Risk for Infection 3. Impaired Skin Integrity 4. Altered Tissue Perfusion 5. Alteration in Comfort
An important nursing indication is to monitor children who are depressed for a number of symptoms that could herald increased suicide risk, including all EXCEPT which of the following?
a. panic b. agitation c. somnolence d. anxiety
The nurse demonstrates understanding of the appropriate use of immunosuppressant therapy by anticipating its use in the client with which disorder?
1. Gout 2. Exophthalmus 3. Rheumatoid arthritis 4. Cancer
A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is indicated?
A. Encourage the client to use the incentive spirometer and to cough. B. Administer oxygen by nasal cannula. C. Request a prescription for sodium bicarbonate from the health care provider. D. Inform the charge nurse that no changes in therapy are needed.