The nurse is performing a rapid assessment for each of the following clients. Which of the following clients require immediate medical assistance? Standard Text: Select all that apply
1. The client is pale and is breathing in a shallow manner.
2. The client's oxygen saturation level is 74% and is dyspneic.
3. The client is rating his pain at a 3 out of a 10 on a pain scale.
4. The client is unable to follow directions.
5. The nurse determines that the client's level of consciousness is decreasing.
1,2,4,5
Rationale 1: The client is pale and is breathing in a shallow manner. The client who is pale and breathing in a shallow manner may be exhibiting anxiety. This client should receive immediate medical attention.
Rationale 2: The client's oxygen saturation level is 74% and is dyspneic. The client who has an oxygen saturation level of 74% and is dyspneic is exhibiting clinical manifestations associated with cardiovascular problems. This client should receive immediate medical attention.
Rationale 3: The client is rating his pain at a 3 out of a 10 on a pain scale. The client who is complaining of only mild pain does not require immediate medical assistance.
Rationale 4: The client is unable to follow directions. The client who is unable to follow directions should be provided with immediate medical attention.
Rationale 5: The nurse determines that the client's level of consciousness is decreasing. The client who has a decreasing level of consciousness during the rapid assessment should be provided with immediate medical assistance. The rapid assessment lasts less than 1 minute. This client's level of consciousness is decreasing very quickly and indicates a severe problem is occurring.
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1. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints. 2. Allowing parents to hold, touch, and rock the dead infant. 3. Advising parents that an autopsy is not necessary. 4. Interviewing parents to determine the cause of the SIDS incident.
The nurse is caring for a 4-year-old girl with vulvovaginitis. The nurse is explaining to the girl's mother how to help prevent subsequent episodes. Which of the following responses indicates a need for further teaching?
A) "She needs to wipe from front to back." B) "I will ensure she changes her underwear every day." C) "She should probably avoid bubble baths." D) "I will help supervise her wiping after bowel movements."
A nurse is reviewing a client's medical record and reads that the client underwent pericardiocentesis earlier in the year. The nurse should discern from this medical term that the pericardium of the client's heart was:
A) Visualized with a camera B) Punctured C) Flushed with a solution D) Measured
The role of the LPN as a team leader has been developed to broaden and improve patient care. The statement that reflects this role implementation is which of the following?
1. As LPN team leaders, these nurses are totally and only personally responsible, under the terms of licensure, for personal care actions and the nursing actions of the others assigned on their unit and shift. 2. As an LPN team leader, this nurse, under the supervision and guidance of an RN, is responsible for all aspects of patient care that is assigned to this team. 3. As an LPN team leader, this nurse uses those skills and judgments learned in school to guide and direct the team members in what the nurse feels is correct patient care. The LPN is accountable only to patients for the care provided. 4. The team leader LPN decides on patient care assignments, taking care to promote accident prevention and safety, and is accountable only to self-professionalism for the nursing actions of the team.