The nurse working in the Emergency Department admits a woman who states she has been raped. The nurse's priority of care includes:
1. Assist the woman to bathe to remove the dirty feeling she reports.
2. Have the woman tested for blood alcohol level.
3. Provide emotional support.
4. Ask the woman to explain exactly what happened.
3
Rationale: The nurse's priority of care is providing emotional support and helping to collect data. Bathing would destroy physical evidence, and should be avoided until after the physical examination is conducted by the provider. The physician will determine if a blood alcohol level is needed, which is unlikely. Asking the woman to explain what happened is inappropriate, and she will be questioned by the police. The nurse should supply emotional support and listen to the client without confrontation.
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A nurse is about to administer flumazenil to a patient who has experienced oversedation from benzodiazepine use. Before administering this drug, the nurse should prepare to manage which patient response?
1. Hypertension 2. Seizure 3. Sudden temperature elevation 4. Bradycardia
Identify the dosage measured on the syringe
What will be an ideal response?
County Hospital has position descriptions for all staff, including RN Team Leaders. Sarah, a team leader on the rehab unit, assesses the needs of the patients in her area, assesses the skills and backgrounds of each of the individuals on her team,
and then assigns and delegates the appropriate care provider to each patient and task. Sarah provides Colleen, her RN colleague with details regarding the patients to whom Colleen has been assigned on the day shift. This is an example of: a. Accountability. b. Responsibility. c. Assignment. d. Delegation.
When a female Mexican American patient and a female nurse sit together, the patient often holds the nurse's hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior. Which analysis is most accurate?
a. The patient is accustomed to touch during conversation, as are members of many Hispanic subcultures. b. The patient understands that touch makes the nurse uncomfortable and controls the relationship based on that factor. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The patient is trying to manipulate the nurse using nonverbal techniques.