A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.
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A woman who is 28 weeks' pregnant has bilateral edema in her lower legs after working 8 hours a day as a cashier at a local grocery store. She is worried about her legs. What is the nurse's best response?
a. "You will be at risk for development of varicose veins when your legs are edematous." b. "I would like to listen to your heart sounds. Edema can indicate a problem with your heart." c. "Edema is usually the result of too much salt and fluids in your diet. You may need to cut down on salty foods." d. "As your baby grows, it slows blood return from your legs, causing the swelling. This often occurs with prolonged standing."
The nurse notes that the patient who has undergone cardiac surgery is now nauseated, restless, confused, and experiencing peaked tall T waves in the ECG. The nurse suspects the patient may be experiencing symptoms of:
A) Hypocalcemia B) Hypercalcemia C) Hyperkalemia D) Hypermagnesemia
To determine the symmetry of a patient's chest wall, the nurse would do which of the following? Select all that apply
a. Stand behind the patient. b. Inspect the right and the left anterior thoraxes. c. Note the shoulder height, observing any differences between the two sides of the chest wall, such as the presence of masses. d. Move in front of the patient. e. Inspect the right and the left posterior thoraxes, comparing right and left sides. f. Note the position of the scapula.
The leadership behavior of analyzing the effect or outcome of action or the worth of an idea according to some standard is
a. Analyzing b. Evaluating c. Questioning d. Summarizing