A child with a history of seizures arrives in the emergency department in status epilepticus. What is the nurse's initial action?
1. Take vital signs.
2. Establish an intravenous line.
3. Perform rapid neurological assessment.
4. Maintain patent airway.
4
Rationale 1: Taking vital signs is important, but airway always comes first.
Rationale 2: Once the airway is secure, securing an IV is vital.
Rationale 3: A rapid neurological assessment is appropriate once the airway is secure.
Rationale 4: Airway is always the priority of care.
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Which of the following client events would require an incident report?
a. The client develops a rash when taking a medication. b. The nurse notes a change in the client's condition. c. The client's relatives complain about the client's care. d. The client falls out of bed.
An 88-year-old client will be discharged from the hospital on a variety of medications. How can the nurse best ensure that the client is capable of taking the medication safely at home?
A. Have the client actively participate in drug administration during hospitalization. B. Include the client's children in discussions regarding proper medication adminis-tration. C. Give the client a pamphlet outlining the actions, side effects, and doses of all prescribed drugs. D. Make a chart for the client, showing exactly which drugs are to be taken at dif-ferent times during the day.
The nurse is reviewing with the client the three major layers of the heart wall and how they relate to the pericardium. What is the best description by the nurse to the client about the endocardium layer of the heart?
A) Thick, strong muscles making up the middle layer B) Thin outer layer of the cardiac wall C) A membrane lining the heart's interior wall D) Outermost layer anchoring the heart
Arrange the five steps of the evidence-based practice process in order of their use. Choice
1. Evaluate practice decisions. Choice 2. Collect best evidence. Choice 3. Integrate the evidence. Choice 4. Appraise the evidence. Choice 5. Write a PICO question.