The nurse who is working in a flu immunization clinic assesses for a situation with a patient that will require a postponement of immunization, such as:
a. history of asthma.
b. taking herbal remedies such as valerian and ginkgo biloba.
c. diabetes that is poorly controlled.
d. having been given immune globulin 2 weeks ago.
D
Immune globulin will decrease the immune response to the vaccine, rendering it useless. Asthma, ginkgo biloba, and uncontrolled diabetes do not prevent an individual from receiving a flu im-munization.
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Which statement indicates that the patient who has had an abdominal hysterectomy needs further home teaching?
a. "I understand I can lift as much as 20 lb." b. "I'm leaving today to stay with my daughter, who lives 20 miles away. My husband plans to drive the family car." c. "The doctor said I can't have sexual intercourse for 4 to 6 weeks." d. "I'm going to miss wearing my girdle or knee-high hose."
During a previous prenatal visit, the nurse focused on the importance of adequate nutritional intake with a pregnant patient. Which assessment findings indicate that this teaching has been effective? (Select all that apply.)
A) Shiny hair B) Smooth tongue C) Conjunctiva pale D) Chipped finger nails E) Normal muscle reflexes
The nurse sees a depressed patient who has psychomotor retardation leaving the dining room. The patient's shirt is soiled from spilled food. The nurse should
a. foster independence by suggesting changing shirts. b. ignore the spill to avoid embarrassing the patient. c. assist the patient to change into a clean shirt. d. notify the patient of the soiled shirt.
The NCSBN Delegation Decision-Making Tree (1997) consists of four steps that guide delegation of nursing tasks
When the nurse assesses the assistant's understanding of how the task is to be performed, when and what information is to be reported, and addresses any unique client characteristics and expectations, which of these four steps is he or she acting under? a. assessment b. planning c. communication d. evaluation