A patient who had extensive surgery asks the nurse for pain medication for a pain of 9 on a scale of 0 to 10. The nurse completes an assessment of this patient's pain and agrees to give pain medication
When the nurse returns to the patient with the ordered intravenous pain medication, she notices the patient's eyes are closed and he appears to be sleeping. What is the nurse's appropriate action at this time?
a. Lock up the medication in a safe location until the patient awakens.
b. Arouse the patient to confirm he still wants the medication.
c. Give the medication as ordered and agreed to.
d. Consult a colleague about what action to take.
ANS: C
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The nursing intervention that constitutes false imprisonment is:
a. The client is confused and combative. He insists that no one can stop him from leaving. The nurse restrains him without a physician's order, then seeks the order. b. The client has been "pesky," seeking the attention of nurses in the nurses' station much of the day. Now the nurse escorts him to his room and tells him to stay there or he'll be put into seclusion. c. A psychotic client, admitted as an involuntary patient, runs out of the psychiatric unit. The nurse runs after him and succeeds in talking the client into returning to the unit. d. A client, hospitalized as an involuntary admission, attempts to leave the unit. The nurse calls the security team and, acting on established protocol, they prevent him from leaving.
Which of the following reflects the most accurate use of an etiology?
a. Knowledge deficit related to abdominal ultrasound b. Knowledge deficit related to incorrect use of walker c. Knowledge deficit related to diabetes d. Knowledge deficit related to age
While assessing a client with PIH on magnesium sulfate, the nurse finds that her output for the last hour was 30 mL, her respiratory rate is 20 per minute, her blood pressure is 150/94, and her deep tendon reflexes are absent
The nurse's next response would be to a. chart her findings c. decrease the magnesium sulfate b. check for clonus d. notify the physician
The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is:
a. Vision. b. Hearing. c. Smell. d. Taste.