A patient asks the nurse to leave his sleeping pill at the bedside because he's not ready to go to sleep. Which of the following should the nurse do?
a. leave the pill as requested
b. tell the patient to call the nurse when he is ready for his medication
c. tell the patient he can take it now or not at all since this is when it is ordered
d. leave the pill as requested and check back in half an hour to be sure the patient took the medication
B
The nurse should not leave the medication at the bedside or tell the patient to take it now or not at all. The safest activity for the nurse to do would be to instruct the patient to call for the nurse when he is ready to take the medication. The nurse should observe the patient swallow the medication. No medications should be left unattended.
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A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.
The nurse is caring for a client who is experiencing acute hemorrhagic shock. The client's blood pressure is 60/28. How will the nurse assess this client's pulse?
1. Measure the radial pulse for 1 minute. 2. Measure the brachial pulse for 1 minute. 3. Measure the radial pulse for 30 seconds and multiply by 2. 4. Measure the client's apical pulse for 1 minute.
A client has a nonpalpable skin lesion that is causing a change in skin color greater than 1 cm in diameter. The nurse would document this finding as being a(n):
1. patch. 2. macule. 3. wheal. 4. vesicle.
At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me feel like my life is back in balance."
The nurse responds, "I think it would be worthwhile to have two more sessions to explore why your reactions were so intense." Which analysis applies? a. The patient is experiencing transference. b. The patient demonstrates a need for continuing support. c. The nurse is having difficulty terminating the relationship. d. The nurse is empathizing with the patient's feelings of dependency.