For each order listed in the chart, state whether the order is appropriate or not and state why
What will be an ideal response?
1, Yes. VS per routine: Need to establish a baseline status to determine changes; should include pain
assessment.
2, No. Neurologic checks every 4 hours: A patient with a suspected head injury would require
frequent neurologic checks beginning immediately on admission to establish a baseline status
and monitor for changes.
3, Yes. TCDB and IS every 2 hours should begin and continue while awake; might need to perform
more frequently, depending on patient condition.
4, No. An ice pack rather than heat would be appropriate while elevating right lower extremity and
right upper extremity to prevent additional edema formation.
5, Yes. Neurovascular checks every hour: need to establish baseline circulation, movement,
sensation, and swelling; then evaluate for any changes signaling potential complications.
6, No. NPO: The patient should be NPO after anesthesia until a gag reflex returns. K.B. is taking ice
chips without difficulty and may be offered clear fluids as diet advances.
7, Yes. IV fluids D5
½NS at 100 mL/hr: Need to assess that site is patent and intact and that solution is
correct.
8, Yes. Morphine sulfate 5 mg IV every 4-6 hours prn: Need to assess pain with VS, administer
morphine as needed, verify whether medication was given in the PACU, administer within time
frame ordered. Additional medication orders may need to be obtained if pain is not controlled
with this dosage.
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Which explanation by the nurse explains to a patient that water should be taken with a tablet?
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A patient is admitted to the Neuro ICU with a C4 spinal cord injury. When writing the plan of care for this patient, what nursing diagnoses would the nurse document as a priority for this patient?
A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously
The school nurse notices that overweight students are bullied by their peers and often have low self-esteem. Which action should the nurse take?
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