The nurse is receiving a victim of a traumatic amputation in the emergency department. What should the nurse do with the amputated limb? (Select all that apply.)
a. Place on ice
b. Rinse with saline
c. Place in ice water
d. Wrap in sterile gauze
e. Place in a sealed plastic bag
ANS: A, B, D, E
The amputated part is rinsed with saline solution, wrapped in sterile gauze, and placed in a sealed plastic bag, which is then placed on ice. C. The amputated part is not covered with ice or in ice water.
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When a client, aged 5 years, is disruptive the nurse tells her "You must take a time-out.". The
expectation for the child is that she will a. go to her room until called for the next meal. b. slowly count to 20 before returning to the milieu. c. sit quietly on the lap of one of the staff members. d. sit on the periphery of the activity until able to regain self-control and review the episode.
A nurse is assessing a patient for delirium versus dementia. What should the nurse expect the patient with dementia to display?
a. Intermittent fear affect b. Perplexity affect c. Bewilderment affect d. Flat affect
The nurse finds a patient slumped to the floor and unconscious, with no pulse or respiration. The nurse should begin the protocol of:
1. basic life support. 2. advanced life support. 3. cardiopulmonary resuscitation. 4. first aid care.
The nurse is planning instruction to support health promotion behaviors. Which of the following clients would benefit the most from these instructions?
1. 60-year-old client diagnosed with type 2 diabetes mellitus 2. 83-year-old client with hypertension 3. 75-year-old client recovering from a total hip replacement 4. 35-year-old client desiring to begin an exercise program