A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect?
A) Diabetic ketoacidosis
B) Renal failure
C) Narcotic overdose
D) Severe brain damage
D
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An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."
A nurse completes an occurrence report. Which is the best way for the nurse to document this occurrence?
a. "Patient found lying on right side on floor. No noted injuries, patient stated, ‘I slipped on a wet spot on the floor. I don't think I am injured.'" b. "Patient slipped on a wet spot on the floor. No noted injuries, physician notified." c. "Patient in too much of a hurry and was walking too fast and fell. Was not injured. Patient instructed to slow down and not be in such a hurry. Health care provider notified." d. "Patient fell while going outside to smoke. Patient denied any injuries. Health care provider notified. Patient counseled."
The nurse caring for an adult client in the intensive care unit (ICU) is given a verbal prescription by a first-year medical resident
The nurse determines that the best course of action is to check with the attending healthcare provider before implementing the prescription. Which is the rationale for why the nurse is experiencing conflict regarding this situation? A) The resident seems unsure of the prescription. B) The nurse only takes prescription from attending healthcare providers. C) The nurse does not like first-year residents. D) The nurse may not trust the resident to make the best care decisions.
A patient asks the nurse how long it will be before a leg wound heals. What phases of wound healing should the nurse explain to this patient?
Select all that apply. 1. inflammation 2. deconstruction 3. reconstruction 4. resolution 5. dissolution