While completing an admission assessment on a newborn the nurse notes poor tone, low temperature, and jitteriness. What is the most appropriate nursing intervention at this time?
A) Check infant temperature, again
B) Complete an entire set of vital signs
C) Assess the infant's blood glucose
D) Check oxygen saturation of the blood
Ans: C
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An older client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a low oxygen saturation level and becomes short of breath when eating. Why should the nurse recommend that this client be on a high-fat high-protein diet?
a. The risk of heart disease is low because of the client's age b. Allows a weight gain and develop muscle to aid with recovery c. Provides more calories per bite to permit less food intake but with more calories d. Foods high in protein and fats are easier to digest and less likely to cause indigestion
A client with ARDS has severe air hunger and is extremely anxious. The nurse would administer which medication to help both problems?
a. Lorazepam (Ativan) b. Morphine sulfate (morphine) c. Furosemide (Lasix) d. Nitroglycerin (Tridil)
A nurse who will be delegating some nursing tasks to other staff members has considered the client's health care status and stability of condition, the predictability of risks and responses, the setting where the care occurs, and the complexity of
the task being performed. Which of the four steps of the NCSBN Delegation Decision-Making Tree was used? a. assessment b. communication and planning c. surveillance and supervision d. evaluation and feedback
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to
a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.