The nurse is caring for a 45-year-old patient who reveals that recent injuries are a result of domestic violence. The patient begs the nurse not to "tell." What action, taken by the nurse, is correct?
1. Report the revelation to the charge nurse.
2. Tell the patient that the law requires reporting this incident.
3. Promise the patient not to tell anyone.
4. Talk with the patient about the reason for secrecy.
4
Rationale: The nurse should not reveal the information to anyone until further assessment is done.
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The nurse is deciding tasks to delegate to other caregivers. What should the nurse use to help making these delegation decisions?
1. Age. 2. Education. 3. Ability for self-care. 4. Ability to pay for services.
Which of the following patients is most at risk for digoxin toxicity resulting from impaired excretion?
a. A 56-year-old man with coronary artery disease b. A 24-year-old woman with cystic fibrosis c. A 53-year-old woman with renal disease d. A 57-year-old man with a hemorrhagic stroke
The nurse's major goal for a client who is at risk for injury is to:
A) Make all choices for the client. B) Remain free from injury. C) Keep the client dependent on the staff for all care. D) Assess the client's mental status.
After conducting a preoperative health assessment, the nurse documents that the patient has physical assessments supporting the medical diagnosis of emphysema
Based on this finding, what postoperative interventions would be included on the plan of care? A) Perform sterile dressing changes each morning. B) Administer pain medications as needed. C) Conduct a head-to-toe assessment each shift. D) Monitor respirations and breath sounds.