A client is becoming increasingly restless, and the nurse is concerned that the client may fall out of bed. After obtaining a health care provider's order for a chest restraint, the nurse applies the restraint to the client
What MUST the nurse document concerning this situation? a. client age, diagnosis, and time restraint is applied
b. generic name of restraint, where applied, and estimated time it will remain in place
c. reason for restraint, type of restraint used, time of placement, and condition of skin
d. name of prescribing health care provider, type of restraint, and time applied
C
Documentation of restraints should include reason for restraint, type of restraint used, time of placement, and condition of skin. In addition, restraints will be released every 2 hours and the client assessed, toileted, and offered food or drink.
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A community health nurse is devoting the day to being a manager. Which of the following activities are part of this role? Select all that apply
A) Orienting three new community health nurses in the agency B) Attending a strategy meeting for a new service the community will be offering C) Working with a team to direct a smoking cessation program D) Investigating an outbreak of salmonella in the community E) Tabulating the findings of a study exploring immunization practices among teens F) Reviewing staff evaluations to assist with planning future in-services
A client with mitral stenosis develops a productive cough with pink, frothy sputum. The best interpretation made by the nurse would be to further evaluate for which complication?
A) Pulmonary edema B) Congestive failure C) Thrombophlebitis D) Cardiogenic shock
A patient is brought to the emergency
department for treatment of a suspected overdose. The patient was found with an empty prescription bottle of a barbiturate by his bedside. He is lethargic and barely breathing. The nurse would expect which immediate intervention? a. Starting an intravenous infusion of diluted bicarbonate solution b. Administering medications to increase blood pressure c. Implementing measures to maintain the airway and support respirations d. Administrating naloxone (Narcan) as an antagonist
Which of the following is not considered to be a barrier to creative thinking?
a. fear of making mis-takes c. hasty decision mak-ing b. open mindset d. stereotypical percep-tion of client care