The nurse is creating a four-column plan of care for a client. For which areas should the nurse prepare to document when creating this care plan?
Select all that apply.
A) Medications
B) Nursing diagnosis
C) Goals
D) Interventions
E) Evaluation
Answer: B, C, D, E
The column plan of care uses columns to categorize data for each phase of the nursing process. This type of care plan may include four columns: (a) nursing diagnoses, (b) goals/desired outcomes, (c) nursing interventions, and (d) evaluation. Medications are not listed on the plan of care.
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The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital should cause the greatest concern?
1. "Blood pressure 110/68, pulse 90." 2. "Clear fluid is leaking from the vagina." 3. "Client is positioned in a left lateral tilt." 4. "Entrance wound present below the umbilicus."
You are dispatched to a residence at 6:15 AM for an unconscious 3-month-old infant who is not breathing. Upon arrival at the scene, you find the father performing CPR on the infant. The infant's mother is sitting on the couch, crying. Your assessment reveals that the child is apneic and pulseless. His skin is pale and cold, and there is gross lividity to his chest. You should:
A) continue CPR and assess the infant's cardiac rhythm to confirm asystole. B) recognize that the infant has been deceased for an extended period of time. C) pronounce the infant dead if he does not respond to 5 minutes of full ACLS. D) tell the parents that the child likely suffocated because he slept on his stomach.
During a client's case conference, a nurse has made reference to the Code of Ethics for Nurses of the American Nurses Association (ANA). What is the main characteristic of the ANA Code of Ethics for Nurses?
A) It provides descriptions of case studies in which ethical dilemmas were resolved. B) It provides standards of conduct for nurses regarding ethical care. C) It outlines a decision-making framework for resolving ethical dilemmas. D) It provides definitions of ethical principles and how they relate to nursing practice.
A nurse is inserting an indwelling catheter into a female patient. Which is the most important first step in maintaining a sterile field
a. never turn your back to the sterile field b. unfold sterile drape away from your body c. when adding sterile supplies, hold 10-12 inches above the field and allow them to drop d. inspect the sterile kit for package integrity, contamination and moisture