What intervention is most appropriate when a culturally diverse client appears insulted by an assessment question, the nurse has asked?
A) Apologizing immediately for obviously offending the client.
B) Inquiring among the client's family if this is how the client typically responds to personal questions.
C) Documenting the client's response in the medical record and then readdress the assessment topic later.
D) Asking the client if they have been offended and if so discussing how the problem can be avoided in the future.
D
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The nurse specializing in nursing informatics uses the computer for what tasks? (Select all that apply.)
1. Documenting patient care 2. Learning about medication side effects 3. Finding evidence-based research related to patient care 4. Scheduling staff work shifts 5. Programming new software
A client with otitis media asks how an infection can occur that deep into the ear. The best response by the nurse is:
1. "The eustachian tube is connected to the nasopharynx." 2. "The eardrum only protects the inner ear from infection." 3. "The infection begins because you put your fingers in your ear." 4. "Swimming introduces bacteria into the middle ear."
A client is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which nursing intervention is the priority?
a. Keep the client sedated to prevent tube dislodgement. b. Maintain balloon pressure at between 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal sa-line. d. Maintain the client's airway.
The nurse notes that the fetal heart rate increases from 140 to 160 with every contraction the mother experiences. The nurse would:
A) consider this response normal, and continue to monitor. B) turn the woman onto her side. C) notify the physician and prepare for a cesarean section. D) notify the nursing supervisor.