Before completing a blood pressure on an adult, which should the nurse do next after introducing self?
A. Provide privacy.
B. Perform handwashing.
C. Identify the client with two identifiers.
D. Explain what he or she will be doing with the client.
Answer: C
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A patient with head trauma is being monitored with an intraventricular catheter device (IVC). The patient's intracranial pressure (ICP) had been staying around 20 mm Hg, but moments ago, it spiked up to 55 mm Hg
What complication related to the monitoring device itself would best explain this dramatic increase in ICP? A) Infection at the catheter access site B) Obstruction of the catheter C) Hemorrhage D) Misplacement of catheter
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8 degrees F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority?
A) Hypothermia related to heat loss during birthing process B) Impaired parenting related to addition of new family member C) Risk for deficient fluid volume related to insensible fluid loss D) Risk for infection related to transition to extrauterine environment
A nursing assistant tells the psychiatric nurse that normal people do not have mental disorders. What action by the nurse is most appropriate?
1. Instruct the nursing assistant that anyone can have a mental health disorder. 2. Alert the nursing manager of the nursing assistant's remark. 3. Refer the nursing assistant back to the psychiatric orientation materials. 4. Disregard the comment because the nurse has no responsibility in this situation.
Automobile safety requires children over 70 pounds to use a booster seat
Indicate whether the statement is true or false