The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
a. Measuring the infant's length by using a tape measure
b. Weighing the infant by placing him or her on an electronic standing scale
c. Measuring the chest circumference at the nipple line with a tape measure
d. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones
ANS: C
To measure the chest circumference, the tape is encircled around the chest at the nipple line. The length should be measured on a horizontal measuring board. Weight should be measured on a platform-type balance scale. Head circumference is measured with the tape around the head, aligned at the eyebrows, and at the prominent frontal and occipital bonesâ€"the widest span is correct.
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The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order?
1) Repeat the order to the prescriber even if she believes she understood the order correctly. 2) Immediately notify the pharmacy of the order and verify it with a pharmacist. 3) Ask the unit secretary to listen to the prescriber on the phone to verify the order. 4) Transcribe the order onto note paper and verify the dosage in a drug handbook.
You are a nurse caring for a patient who is having a GI bleed. You say to his wife: "It is so fortunate that you brought him to the emergency room. You were right in thinking that he needed immediate medical attention
" This is a therapeutic statement for which of the following reasons? 1. It is an open-ended question that encourages conversation. 2. It is circular questioning that focuses on relationships. 3. It commends the family member and empowers them in the situation. 4. It makes the family member feel that she has been heard.
The nurse is identifying patient demographic groups that are at increased risk for needing insulin to control blood sugar
Which patient groups would the nurse identify? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Patients who are fasting or malnourished 2. Patients with type 2 diabetes who are diagnosed with an infection 3. Patients with type 2 diabetes who are undergoing surgical procedures 4. Patients with gestational diabetes 5. Patients receiving total parenteral nutrition
The best way for the nurse to evaluate the parent's ability to administer medications is:
a. have more than one nurse explain the procedures at different times during the child's hospitalization. b. have the parents verbally explain medication administration to their child and document that the parents demonstrated verbal understanding. c. provide the parents with a demonstration of medication administration, both during hospitalization and prior to discharge. d. have the parents demonstrate the procedures to the nurse after the nurse has explained and demonstrated the procedures.