A nurse receives a report from the microbiology department that a client's blood culture is positive for gram-negative rods. The client is not on antibiotics. Which of these steps should the nurse take FIRST?
a. Document the result in the appropriate area of the chart.
b. Inform the client that the cause of illness has been identified.
c. Notify the health care provider, and document the results and the time the health care provider was notified.
d. Place the laboratory report on the client's chart as soon as possible.
C
The decision the nurse makes should be done in the best interest of the client based on reliable information and made using critical thinking. In this scenario, the most appropriate actions by the nurse would be to notify the health care provider and document the results and the time the health care provider was notified.
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When responding to a patient who has agitated, hostile behavior during a community meeting, the initial action the nurse should take is to:
a. follow the treatment plan. b. place the patient in seclusion. c. offer an antianxiety medication. d. permit the angry outburst if no harmful behavior is threatened.
A client is taking goserelin (Zoladex). What periodic assessment does the nurse plan for this client?
a. Weight and abdominal girth b. Pulmonary function tests c. Bone density testing d. Abdominal ultrasound
Which of the following is the most common cause of fires in the home?
1. cigarette smoking 2. heating and cooling units 3. gasoline stored in plastic containers 4. use of an electric stove
On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred
What nursing action should be taken first? A) Notify the client's surgeon. B) Position the client in bed with knees bent. C) Cover the area with a large saline-soaked dressing. D) Pack the wound with nonadherent gauze.