A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next?
a. Auscultate breath sounds.
b. Administer the PRN morphine.
c. Have the patient cough forcefully.
d. Notify the patient's health care provider.
ANS: A
The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
You might also like to view...
What is included when the LVN/LPN completes the Resident Assessment Instrument (RAI)?
a. Minimum Data Set (MDS) and the signature of the physician b. Resident Assessment Protocols (RAPs) and the drug list c. Minimum Data Set, Resident Assessment Protocols, and the RN's signature d. Resident Assessment Protocols and the signature of the administrator
The nurse is assessing a patient admitted with a newly diagnosed bleeding duodenal ulcer. He is exhibiting physiological signs of anxiety and seems to have difficulty concentrating
During the interview, the patient tells the nurse that he is often "short of breath" and says, "I lie awake nights worrying about everything." He has been unable to work or care for his family for the past 6 months. What is the nurse's priority after documenting this information in the nurses' notes? a. Provide emotional support for the patient using reflective listening technique. b. Do nothing; people with duodenal ulcers typically cannot work. c. Question the patient's family about the information received from the patient. d. Notify the primary care provider and ask for a referral to a mental health professional.
As the executive director of the local animal humane society, you work with several employees who are at varying levels of experience in working with animal welfare issues and with varying degrees of motivation to continue this important work
Using Situational Leadership® concepts, you should a. Adapt your style based on experience and skill level of the staff b. Adapt your leadership style based on the motivation level of the staff c. Demonstrate a high degree of flexibility in your style to each staff member d. Demonstrate little flexibility in your style as you interact only with high-level staff members
What is the most common cause of Addison disease?
a. An autoimmune reaction b. Dietary deficiency of sodium and potas-sium c. Cancer d. Viral infection of the pituitary gland