The unit is busy, and you are concerned about monitoring T.C. carefully enough. your present patient load
is six; of these, two patients are newly postoperative and one is getting ready for discharge.
you have one
experienced unlicensed assistive personnel (UaP) to help you. you are concerned that T.C.'s respiratory
status may further decline.
Formulate a plan for the UAP and you to care for T.C. during your shift.
Depending on unit protocol, you need to either stop the PCA therapy or make certain the control to
the PCA pump is not accessible or locked out to T.C. until she is completely awake. This removes the
possibility that she might self-administer a dose of opioid medication that would further depress
her respiratory status. After you perform a complete assessment, work out a schedule with the UAP
so that one of you will monitor VS, level of consciousness, and Spo2
every 15 minutes until T.C. is
more awake. Give specific parameters to the UAP for which you would need to be notified. Instruct
the UAP that you want T.C. to continue on oxygen therapy. You will be responsible for performing
subsequent assessments and teaching T.C. regarding coughing, deep breathing, and using the
incentive spirometer; the UAP can then remind T.C. to perform these activities hourly. The UAP can
assist T.C. with changing positions at least every 2 hours.
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The nurse is caring for a school-age client who will be discharged from the hospital after receiving a ventriculoperitoneal (VP) shunt as treatment for increased intracranial pressure (IICP)
The nurse has taught the parents to monitor the child for shunt malfunction. Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met? A) "If our child has a bulging soft spot, we will call the doctor." B) "If our child develops an altered level of consciousness, we will notify the doctor." C) "If we notice our child's head is expanding, we will notify the doctor." D) "If our child develops sunset eyes, it will be important to call the doctor."
The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn?
1. "You appear to be Muslim. Do you want your son circumcised?" 2. "Let me explain newborn care here in the U.S." 3. "Your baby is a U.S. citizen. You must be very happy about that." 4. "Could you explain your preferences regarding childrearing?"
Care is given during the:
a. Assessment step of the nursing process b. Planning step of the nursing process c. Implementation step of the nursing pro-cess d. Evaluation step of the nursing process
Which will the nurse include in the family assessment for the postpartum client? Select all that apply
1. Parental roles 2. Bonding behaviors 3. Sibling adjustment 4. Signs and symptoms of infection 5. Level of comfort with newborn care