After a patient has fallen, the most appropriate nursing intervention is to:
1. apply a vest restraint.
2. have the patient begin ambulating as soon as possible.
3. administer Haldol (haloperidol) as ordered, PRN.
4. apply wrist restraints.
2
The patient should begin ambulating as soon after a fall as possible to prevent the hazards of bed rest and restore confidence. It is tempting to apply restraints after a fall, but it is best to avoid the use of restraints, if possible.
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The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid–base imbalance is most likely to occur?
A) Respiratory alkalosis B) Metabolic alkalosis C) Respiratory acidosis D) Metabolic acidosis
A patient has a PT of 40 seconds and an INR of 3.3 and is vomiting blood. Which of the following should the nurse anticipate administering?
a. Protamine sulfate 20 mg orally b. Protamine sulfate 20 mg slowly IVP c. Phytonadione (vitamin K) 2.5 mg orally d. Phytonadione (vitamin K) 1 mg in 50 mL D5W infused over 1 hour
John notes that the next section is specific to the organizational philosophy and has a four-point ordinal scale that describes performance from "always meets expectations" to "does not meet expectations."
This type of evaluation is most commonly known as: a. A behavior-anchored rating scale. b. Management by objectives/learning goals. c. The forced distribution scale. d. A graphic rating scale.
Dressings serve several functions. Which of the following is a function of a dressing? (Select all that apply.)
a. Maintains a moist environment b. Prevents the spread of microorganisms c. Increases patient comfort d. Controls bleeding