The nurse is admitting a patient scheduled this morning for lumpectomy and axillary lymph node dissection. Which action should the nurse take first?
a. Teach the patient how to deep breathe and cough.
b. Discuss options for postoperative pain management.
c. Explain the postdischarge care of the axillary drains.
d. Ask the patient to describe what she knows about the surgery.
ANS: D
Before teaching, the nurse should assess the patient's current knowledge level. The other teaching also may be appropriate, depending on the assessment findings.
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When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?
a. While listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it. b. While auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations. c. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. d. While firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.
The nurse is planning care for a group of patients. Which of the following activities may be delegated to unlicensed assistive personnel?
a. Analysis of the patient's physical condition b. Morning vital signs, height, and weight. c. Evaluation of whether colostomy drainage is normal d. Determining patient readiness for postsurgical learning
A nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute with fetal movement in a 20-minute period is termed:
a. nonreactive. b. positive. c. negative. d. reactive.
A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy — namely, the nurse the client is talking to at the time. This client is demonstrating which behavior?
A. Confidentiality B. Splitting C. Empathy D. Gnawing