The patient is an older male with the diagnosis of "dementi
a." He is confused and wanders and is occasionally combative. The physician orders "Posey vest (restraint vest) PRN." The nurse should:
a. Place the Posey vest on the patient as needed
b. Inform the physician that the order is inappropriate
c. Check the condition of the patient every 2 hours after application of the vest
d. Ignore the order
B
This order must never be written as a standing order or on an as-needed basis (i.e., prn); the condition of the restrained or secluded patient must be continually assessed, monitored, and reevaluated. Consultation with the patient's treating physician should occur as soon as possible if the restraint or seclusion is not ordered by the patient's treating physician.
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Mrs. Flowers calls the physician's office you work for complaining of reddish orange urine and sputum. After pulling the chart, you
a. Tell her to come right over to be evaluated b. Ask her if she has been taking her rifampin for TB and explain that this may be frightening, but that it is normal c. Ask her if she has been taking her rifampin for TB and explain that this is a side effect and she should stop taking the medication immediately d. Explain that this is a normal symptom of TB
A health care service that provides a defined population with a stated range of services through prepayment of an annual or monthly capitation fee is a(n)
a. health maintenance organization (HMO). b. nurse-managed ambulatory center. c. outpatient service of a community hospital. d. preferred provider organization (PPO).
When checking the patient's back, the nurse pushes her thumb into the patient's sacrum. An indentation remains. The nurse charts that the patient has
a. sacral compromise. b. delayed skin turgor. c. pitting edema. d. dehydration.
On admission to the acute care unit a patient tells the nurse that she stopped taking her prescribed clonazepam (Klonopin) 2 days ago. What is the nurse's best first action?
a. Ask the patient why she stopped taking the clonazepam. b. Administer a dose of clonazepam immediately. c. Document this information as the only action. d. Notify the prescriber and watch for seizures.