The nurse is assessing clients in the postanesthesia care unit (PACU). A client is shivering and has a temperature of 95.4° F (35.2° C). What is the nurse's best action?
a. Get the client warm blankets.
b. Elevate the head of the bed.
c. Auscultate the client's lungs.
d. Assess the client's oxygen saturation.
D
Hypothermia can cause shivering and hypoxemia. The nurse first should assess the client's oxy-gen saturation, then should apply warm blankets to bring the client's temperature up to a normal level. The other two actions may be needed but not as a priority.
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The nurse is caring for a client who had a left mastectomy several years ago and was admitted to the acute care facility secondary to lymphangitis
What nursing interventions will be included in the plan of care? Standard Text: Select all that apply. 1. Increase activity levels. 2. Elevate left arm. 3. Application of heat to the left arm 4. Massage of the left arm 5. Keep the client in the supine position as often as possible.
During a well-baby health maintenance visit, the nurse notices the infant does not demonstrate expected developmental milestones for age. Which nursing intervention is the priority in this situation?
1. The nurse should initiate a consult with social services for a home assessment. 2. The nurse should consult with the health care provider. 3. The nurse should ask the parents questions about their play activities with the infant. 4. The nurse should prepare the family for a potentially upsetting diagnosis.
Although some subjectivity is inescapable in performance appraisals, what action can the manager take to arrive at a more fair and accurate assessment?
A) Written anecdotal notes regarding the employee's performance should be maintained throughout the evaluation period. B) Evaluation criteria that reflect on the employee as a person rather than just on work performance should be used. C) Data gathered by the manager in preparation for the performance appraisal should be limited to no more than two sources, so no conflicting information is received. D) The manager should rate all employees using central tendency whenever possible.
A nurse is irrigating pressure ulcers on a patient's coccyx. When the patient asks how they are healing, the nurse grimaces and says, "Oh, they're doing just fine." This is
a. incongruence between verbal and nonverbal messages. b. a confirming statement. c. objectivity in responding to the question. d. the therapeutic use of humor.