The nurse is preparing to perform a rapid assessment. Which initial action should the nurse take?
A. Perform hand hygiene
B. Identify yourself and explain that you will be providing care for a given time period.
C. Note isolation precautions, latex allergies, or fall precautions.
D. Enter the room.
Answer: A
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The nurse correctly identifies which patient as having the greatest risk for infection?
a. An 80-year-old male with an enlarged prostate b. A 24-year-old female long-distance runner c. A 50-year-old obese male d. A 40-year-old sexually active female
The nurse is caring for a client in the PACU who is ready for extubation. What should the nurse do before the endotracheal tube is removed?
a. Auscultate for bilateral breath sounds b. Check for Homans' sign c. Assess capillary refill d. Assess for Cullen's sign
A patient at risk for the development of skin cancer is discussing sun exposure prevention with the nurse. What information should be included in the discussion?
Select all that apply. 1. A higher-rated sunscreen is needed between 10 a.m. and 3 p.m. 2. Sunscreen is needed even on cloudy days. 3. Apply a sunscreen with an SPF of 15 or more. 4. The higher the sunscreen rating, the less the protection provided. 5. When swimming, sunscreen should be reapplied every 4 hours.
The nurse is providing discharge education for a client who experienced an anaphylactic reaction as a result of a bee sting
In order to best assure the client will receive prompt, appropriate medical care in the event of another bee sting, the nurse encourages the client to: Select al that apply. 1. Wear a medical alert bracelet that identifies his allergy to bee venom. 2. Always have quick access to an epinephrine pen. 3. Be aware of how quickly the symptoms occur and exacerbate. 4. Minimize the amount of time spent out of doors. 5. Apply insect repellant before spending time outside.