The nurse is assessing for hepatojugular reflux in a patient with a history of heart failure. When performing this assessment, the nurse will:
A) Elevate the patient's head to 90 degrees
B) Press the patient's right upper abdomen
C) Palpate the patient's jugular veins simultaneously
D) Lay the patient flat in bed
B
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A nurse is caring for a 70-year-old woman in the emergency room who is complaining of shortness of breath and has a history of congestive heart failure along with hypertension
She was seen by a new cardiologist this week and was started on four new medications. She thinks one is a new "water pill," and she is unsure about the others. The drugs are very expensive and she is waiting for them to arrive by mail order, so she quit taking all her other medications two days ago. The nurse's best set of interventions would be to: A) Obtain a list of her current medications, check for interactions, and consult the emergency room physician B) Obtain a brief history and vitals, then allow the emergency room physician to sort out the details because he will be ordering the medications C) Obtain a set of vitals, do a focused assessment, compile a list of her medications along with when she took them last, and consult with the emergency room physician D) Obtain a set of vitals, do a complete assessment, compile a list of her medications and exactly when she took them last, then consult with the emergency room physician
Muscle spasticity is noted upon nursing assessment in a spinal cord-injured patient. The nurse would expect which of the following medications to be ordered to control this clinical manifestation?
A) Baclofen (Lioresal) B) Dexamethasone (Decadron) C) Mannitol (Osmitrol) D) Phenobarbital (Luminal)
The nurse assesses that a client's abdominal wound has dehisced. The first thing that the nurse should do is:
a. apply sterile gauze or a pad soaked with sterile normal saline over the wound area that has dehisced. b. place the client in a flat position. c. ask the client to deep breathe and cough. d. apply a dry gauze dressing over the area that has dehisced.
When a nurse delegates a treatment to be performed by other personnel
a. the hospital is ultimately responsible for the treatment b. that other person documents the patient's response to treatment c. the nurse is responsible for ensuring that the treatment was completed according to standards of care d. that other person is ultimately responsible for the patient's response to treatment