While changing a patient's abdominal dressing, the nurse talks about aspects of wound care, the need to check the skin, and the protection of the wound from infection or injury
The nurse and patient are currently in the _________ phase of the nurse?patient relationship. 1. Working
2. Orientation
3. Termination
4. Caring
Working
Rationale: The working phase of the nurse−patient relationship describes the participation of the patient and nurse in interventions to achieve mutually agreed-upon goals. Most patient education occurs during this phase. The orientation phase is the first phase of the relationship in which introductions occur and the trusting relationship begins to develop. The termination phase describes the time during which the nurse and patient review what has occurred during the working phase and the progress of goal achievement. There is not a caring phase within the nurse−patient relationship.
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A patient in the ICU is status post embolectomy after a pulmonary embolus. What does the nurse measure on a patient who is postoperative from an embolectomy?
A) Left atrial pressure B) Pressure in the vena cava C) Pulmonary venous pressure D) Pulmonary arterial pressure
A nurse admits a patient and selects the priority nursing diagnosis of acute pain. The nurse plans to administer pain medication as needed. When the patient complains of pain, the nurse medicates the patient. Next, the nurse should
1. Assess the patient's laboratory values. 2. Create a new nursing diagnosis. 3. Administer an additional dose of medication. 4. Evaluate the effects of the medication.
When assessing teaching and learning needs at discharge, the nurse should focus on which of the following? (Select all that apply.)
a. What potential problems are likely to prevent a safe discharge b. The client's ability to pay for his or her hospitalization c. What potential problems are likely to cause complications or readmission d. What prior knowledge or experience the client and family has with the current problem e. What skills and equipment are needed to manage the problem at home f. Who or what agency will assume responsibility for continuing care
The nurse is caring for a client at risk for sensory overload. What interventions should the nurse implement? Select all that apply
A) Remove clutter from the client's room. B) Implement measures to reduce the client's pain. C) Assist with all ADLs. D) Limit interruptions to the client's rest/sleep times. E) Limit extraneous noise.