The nurse is notes that a patient recovering from a craniotomy has a pink spot with a yellow ring around it on the pillow. What should the nurse do?
a. Change the patient's pillowcase.
b. Do a basic neurological assessment.
c. Notify the charge nurse immediately.
d. Change the patient's cranial dressing.
ANS: C
Drainage that is blood-tinged in the center with a yellowish ring around it may be cerebrospinal fluid (CSF) leakage. A suspected CSF leak should be reported to the charge nurse or physician immediately. A. B. These actions can be completed after the charge nurse has been notified. D. The dressing is changed only with a physician's order.
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The nurse is assisting with endotracheal intubation of the patient and recognizes that the procedure will be done in what order: _______________, _______________, _______________, _______________, _______________?
(Put a comma and space between each answer choice.) A. Assess balloon on endotracheal tube for symmetry and leaks. B. Assess lung fields for bilateral expansion. C. Inflate balloon of endotracheal tube. D. Insert endotracheal tube with laryngoscope and blade. E. Suction oropharynx. Fill in the blank(s) with correct word
In situations where clients are quiet and uncommunicative, which of the following interventions should be implemented by the nurse?
A) Probe the client and emphasize communication. B) Do not wait for reticent clients to share their feelings. C) Avoid assuming that the client has no problems. D) Allow clients to express their emotions without fear.
A home health nurse is assigned to follow-up on a patient recently diagnosed with gastroeso-phageal reflux disease (GERD)
Which primary symptom should the nurse take into considera-tion when updating the nursing interventions on this patient's care plan? a. Nausea b. Vomiting c. Anorexia d. Heartburn
The nurse is identifying ways to increase the oral fluid intake of a preschool-age child. Which interventions should the nurse use with this patient? (Select all that apply.)
A) Provide fluids ice cold. B) Offer small full glasses of fluid. C) Provide the child's favorite fluid. D) Encourage popsicles if permitted. E) Provide a straw if not contraindicated.