A patient about to receive a morning dose of digoxin has an apical pulse of 53 beats/min. What will the nurse do next?
a. Administer the dose.
b. Administer the dose, and notify the prescriber.
c. Check the radial pulse for 1 full minute.
d. Withhold the dose, and notify the prescriber.
ANS: D
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At 10 PM, an older male resident attempts to climb over the bedrails. Which intervention should the nurse implement first?
a. Talk to the resident about his behavior. b. Call the physician, and ask for a sedative. c. Apply a vest restraint on the resident. d. Get a companion to keep him in the bed.
What are the priority nursing interventions in the event of a fire?
a. Calling the fire department and fighting the fire. b. Protecting the patient from injury and con-taining the fire. c. Removing hazards and containing the fire. d. Fighting the fire and preventing secondary outbreaks.
The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as:
1. Stage I 2. Stage II 3. Stage III 4. Stage IV
Which statements by patients diagnosed with a serious mental illness best demonstrate that the case manager has established an effective long-term relationship? "My case manager: (select all that apply)
a. talks in language I can understand." b. helps me keep track of my medication." c. gives me little gifts from time to time." d. looks at me as a whole person with many needs." e. lets me do whatever I choose without interfering."