The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse?
a. Checking to see if the machine is working
b. Keeping controls in a secure place on the bed
c. Placing padding in the machine per request
d. Storing the CPM machine under the bed after removal
ANS: D
For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.
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The nurse visits the client in his home and finds him with a temperature of 100.2°F oral. The nurse's priority action is to:
1. Notify the physician that the client has a fever and obtain an order for antipyretics. 2. Assess the client further to determine possible cause of the fever. 3. Talk with the family members to get information about the client's condition. 4. Obtain a rectal temperature for increased accuracy.
An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center?
a. Level I b. Level II c. Level III d. Level IV
What is the best score a patient can make on the Glasgow Coma Scale?
A) 1 B) 10 C) 15 D) 25
The daughter of an ill patient tells the nurse that her father would not be so sick if she had spent more time with him over the years. The nurse realizes the daughter is exhibiting which of the following cognitive distortions?
1. Personalization 2. Selective abstraction 3. Overgeneralization 4. Magnification