The nurse enters the room of a client with an altered level of consciousness that has just vomited. The nurse suspects aspiration. Which of the following actions should the nurse take first?
1. Count the respiratory rate.
2. Complete a full physical assessment to establish a baseline.
3. Ask the client if a choking sensation is felt.
4. Suction the client and apply oxygen.
ANS: 4
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The nurse is caring for a patient who has central venous pressure (CVP) monitoring in place. The nurse's most recent assessment reveals that CVP is 7 mm Hg. What is the nurse's most appropriate action?
A) Arrange for continuous cardiac monitoring and reposition the patient. B) Remove the CVP catheter and apply an occlusive dressing. C) Assess the patient for fluid overload and inform the physician. D) Raise the head of the patient's bed and have the patient perform deep breathing exercise, if possible.
A mother tells the nurse she is afraid to have her infant immunized. Which of the following statements would be the most appropriate response by the nurse?
a. "It is normal to be concerned, as some immunizations have been linked to au-tism." b. "Researching the Internet will provide you more information as to the importance of immunizations." c. "Choosing not to vaccinate your child puts your child and others at risk." d. "Your infant received active immunity at birth, so immunizations are not indicated until 4 months of age."
Which is an example of a closed wound?
A) Abrasion B) Ecchymosis C) Incision D) Puncture wound
The Outcome Present-State Testing Model is a dynamic, systematic, clinical reasoning process that emphasizes outcomes of care. There are several steps in the process. The family story step provides:
1. Essential information about individual family members and the family as a whole 2. Meaningful clusters of evidence 3. Present state and desired outcomes 4. Clinical judgment