The nurse is collecting data on a 6-year-old child admitted with a possible urinary tract infection. Which vital sign measurement might indicate an infection?
A) Pulse rate 135 bpm
B) Pulse oximetry 93% on room air
C) Respirations 22 per minute
D) Blood pressure 100/70
Ans: A
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After shift report, the nurse is preparing to provide morning care to the assigned clients. Which of the following would be the nursing priority when planning care for the client assignment?
1. Gather all equipment and supplies for each client first. 2. Delegate the bed making to the unlicensed assistive personnel. 3. Assess each client's need for assistance with morning care. 4. Notify each client of the schedule for AM care.
A patient with pancreatitis asks the nurse, "Why are my stools so frothy and smell so bad?" How should the nurse respond?
1. "This is a sign of malnutrition." 2. "This indicates your stools have more fat in them." 3. "This is a sign of peptic ulcer disease." 4. "You may be developing diabetes mellitus."
A patient reviewing his medical record tells the nurse that he does not remember the name of a person who documented the care
The nurse reviews the area in question, sees that the name of the health care provider was not signed correctly and completely, and then should do which of the following? 1. Explain to the patient who the health care provider is and then remind the health care provider to document his or her full name and credentials with every documentation entry. 2. Correct the entry in the medical record. 3. Tell the patient that it is not important. 4. Ask the patient if he has found anything else wrong with the documentation.
Which of the following factors distinguishes home health care from other types of psychiatric–mental health nursing care?
A) The client-centered focus B) The setting C) The focus on strengths D) The focus on rehabilitation