The nurse is caring for a client with an IV, and will be administering a blood transfusion. The following considerations are appropriate when considering the infusion device: Standard Text: Select all that apply
1. Peristaltic regulators are appropriate for administration of blood.
2. The tubing cassette should be held upright when priming.
3. Accurate function of the machine should be verified.
4. Systematically check the IV if the device's alarm is going off.
5. Place a piggyback administration set above the air detector device.
3,4,5
Rationale: Peristaltic regulators are not appropriate for administration of blood, because of their squeezing action, which can injure red blood cells.
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The nurse is preparing to assess the vital signs of a 4-year-old. Which of the following would be the best approach?
A) "We need to assess your vital signs." B) "I am going to see how warm you are and give your arm a hug." C) "Can I take your temperature and blood pressure?" D) "I am going to take your temperature and blood pressure."
The nurse is discussing protein with a client. The nurse describes that protein is formed from essential and nonessential amino acids. The client is having difficulties understanding the difference
The nurse should explain that essential amino acids are what? A) The only amino acids necessary for growth and tissue maintenance B) Amino acids that must be consumed in the diet C) Amino acids that are found only in animal products and soy D) Amino acids that are more important than nonessential amino acids
A patient in labor is requesting pain medication. The nurse assesses her labor status first, focusing on: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. The contraction pattern. 2. The amount of cervical dilatation. 3. When the labor began. 4. Whether the membranes are intact or ruptured. 5. The fetal presenting part.
After working with a client who has a history of violent behavior to identify possible clues that suggest the behavior is escalating, the nurse and client develop a plan for prevention. Which strategy would they be least likely to include?
A) Counting to 10 B) Taking slow deep breaths C) Turning up the music loudly D) Taking a voluntary time out