After reviewing the medical history, the nurse suspects that an older patient would benefit from another dose of the pneumococcus vaccination. What information did the nurse use to make this clinical decision? Select all that apply.
A. Taking medications for hypertension
B. Initial vaccination at age 55
C. Ongoing treatment for prostate cancer
D. History of two hip replacement surgeries
E. Beginning dialysis for chronic renal failure
Answer: E
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The nurse is asked to obtain informed consent for surgery that will be performed on a client the following day. The appropriate action is
1. Explaining the procedure to the client, and having the client sign the form 2. Witnessing the signature, not whether the client understands what will occur 3. Having the client sign a blank form that the physician can fill out later 4. Having a family member talk to the patient to convince them to have the procedure
You are about to take the patient's temperature using a temporal artery thermometer. This procedure would require which of the following steps? Select all that apply
a. Remove the protective cap from the probe head. b. Position the probe head on the center of the forehead, midway between the eyebrow and hairline, and depress the scan button. c. Rapidly, while applying pressure, move the thermometer across the forehead (in either direction) maintaining contact between the probe head and the patient's forehead until the hairline is reached. d. Observe for a blinking light and/or beeping indicating that a measurement is being calculated. e. Release the scan button and remove the thermometer from the patient's forehead. Read the temperature on the display screen. f. Discard the protective cap and the probe.
The nurse is evaluating a patient receiving hydromorphone (Dilaudid). Which findings are adverse effects of this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Pruritus 2. Polyuria 3. Nausea 4. Decreased respiratory rate 5. Tachypnea
Which of the following descriptions of the four stages of labor is correct for both definition and duration?
1. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours 2. Second stage: full effacement to 4 to 5 cm visible presenting part; 1 to 2 hours 3. Third state: active pushing to birth: 20 minutes (multiparous women) 50 minutes (first timer) 4. Fourth stage: delivery of the placenta to recovery: 30 minutes to 1 hour