The nurse has just performed an IV start on a client. After the catheter has been threaded its full length in the client's vein, which action does the nurse perform next?
a. Secure the IV with a securement device or tape.
b. Dispose of the IV needle in the sharps container.
c. Engage the safety mechanism of the IV catheter
d. Note the date and time of the dressing application over the insertion site.
C
A federal law enacted in 2000 requires health care facilities to use IV catheters with an engineered safety mechanism to prevent needle sticks, which can be a source of contamination by bloodborne pathogens. This priority action would help keep the nurse safe. Securing the IV and dating/timing the dressing are also important actions, but engaging the safety mechanism comes first. After engaging the safety mechanism, safely dispose of the needle in the sharps container.
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The nurse is caring for a patient with schizophrenia who is experiencing auditory hallucinations. The patient tells the nurse, "The voices in my head are telling me to do things that I don't want to do."
When planning care for this patient, what is the priority nursing diagnosis that the nurse will formulate? 1. Risk for violence caused by schizophrenia, manifested by command hallucinations. 2. Risk for violence due to auditory hallucinations, as evidenced by command hallucinations. 3. Disturbed thought processes due to schizophrenia, as evidenced by command hallucinations. 4. Disturbed thought processes due to auditory hallucinations, manifested by command hallucinations.
Which of the following descriptions is the best example of how the Beveridge model is implemented?
a. A government system plans and pays for health care delivered by private enterprise. b. Multiple insurance providers develop options for health care delivery to the population. c. A government system plans and pays for health care delivered by private enterprise. d. The government plans and funds care provided by its employees in government-owned health facilities.
The nurse detects a possible irregularity in the rhythm of the client's radial pulse and will:
a. Record this as normal for the client. b. Use a stethoscope to check the brachial pulse. c. Count the client's apical pulse for a full minute. d. Count the radial pulse again for 15 seconds and multiply by 4.
The nurse is witnessing an adult patient's surgical consent. Which of the following would the nurse need to confirm before witnessing the surgical consent? (Select all that apply.)
a. The patient's next of kin b. Whether the patient is informed about the surgery c. If family members have questions related to the surgery d. When the patient last ate or drank e. The last time a sedative was administered