The patient in labor has a contraction interval of 45 seconds. Which action by the nurse is most appropriate?
a. Prepare for immediate delivery.
b. Turn the patient onto her right side.
c. Assist the patient in deep breathing exercises.
d. Report the finding to the registered nurse or physician.
ANS: D
The interval is the time of relaxation between contractions. A consistent interval shorter than 60 seconds may reduce fetal oxygen supply and should be reported to the registered nurse or physician.
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Which dietary modification should the dietician plan and the nurse reinforce to reduce the risk for skin impairment in a client with mobility problems?
A. High protein, high carbohydrate, low fat B. High protein, low carbohydrate, low fat C. High protein, high carbohydrate, high fat D. High protein, low carbohydrate, high fat
What is an example of the weakest source of power?
a. Several nursing students talk with a head nurse regarding a problem they are having on the unit. The head nurse then discusses this problem with the chief nursing officer. b. The clinical nursing instructor sends a student to the skills lab for further prac-tice. c. A nurse shares knowledge regarding nursing in a confident manner and style. d. The head nurse tells staff members that as soon as all the care plans are completed, they may have some additional compen-sation time.
Which patient information does the nurse document in the patient's physical assessment?
a. Slurred speech b. Immunizations c. Smoking habit d. Allergies
The length of immobilization can adversely affect a patient. When assessing patients, nurses need to assess muscle mass for:
A. increased fat. B. increases in strength. C. decreases in strength. D. increases in lean muscle.