A client has an intraventricular catheter. What action by the nurse takes priority?
a. Document intracranial pressure readings.
b. Perform hand hygiene before client care.
c. Measure intracranial pressure per hospital policy.
d. Teach the client and family about the device.
ANS: B
All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.
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The nurse is discussing strategies for preventing sensory impairments with the parents of a newborn. Strategies to protect hearing include: Standard Text: Select all that apply
1. Obtain regular immunizations. 2. Seek medical attention for reduced eye contact. 3. Keep auditory stimulation to a minimum. 4. Have the child wear ear protection in noisy environments. 5. Have regular health examinations.
A client is to receive indomethacin as tocolytic therapy. Which of the following laboratory tests would the nurse expect to be performed as a baseline? Select all that apply
A) Complete blood count B) Serum creatinine level C) Liver function tests D) Amniotic fluid index E) Blood glucose level
Standing in a fast food line, the person in front, while munching on a cookie, begins to cough heavily, with deep inspirations, and waves his arms around wildly. The nurse should immediately:
1. start rescue breathing as quickly as possible. 2. start chest compressions as quickly as possible. 3. perform the Heimlich maneuver. 4. do nothing at this point as long as there is air exchange.
An older adult is being treated for severe pain resulting from a history of osteoarthritis. In her discharge teaching, which information is most important to the successful management of the pain?
a. check for incompatibilities before taking any new medications b. ar-range to take a dose of analgesic prior to physical activity c. to take the analgesic around the clock as prescribed d. be alert for the signs of overdose toxicity