H.K. is a 26-year-old man who tried to light a cigarette while driving and lost control of his truck. The
truck flipped and landed on the passenger side. H.K.
was transported to the emergency department with
a deformed, edematous right lower leg and a deep puncture wound approximately 5 cm long over the
deformity. Blood continues to ooze from the wound.
What further assessment will you make of the leg injury and what precautions will you take
in making this assessment?
What will be an ideal response?
"The five Ps should be assessed: pulses, pain, paresthesia, paralysis, and pallor. However, when an
open fracture is suspected or bone is obviously displaced, the limb should be immobilized and the
patient should not be asked to demonstrate mobility. Toes can be wiggled when fractured legs are
being assessed. Watch for swelling or bone displacement that could place pressure on nerves. Lastly,
be sure to wear gloves and follow Standard Precautions when performing the assessment because
the wound is oozing blood.
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The nurse executive of a health care organization is working with the chief financial officer to develop a method of charging for nursing services. Why is this a difficult undertaking?
1. The historical method of recouping the cost of nursing salaries has been to bundle those costs in with ancillary services salaries. 2. The actual cost of providing nursing services is difficult to determine. 3. The number of patients on a given unit varies from day to day. 4. Nurses do not like to think about charging for their services.
At the unit level, what time frame may be considered long-range planning?
A) 3 months B) 4 months C) 5 months D) 6 months
In most psychiatric units, clients are responsible for requesting their medications at the appropriate time rather than nurses bringing medications to clients' bedsides
When a client asks why he has to ask for his medications, which explanation should be provided by the nurse? A) "It provides reality orientation." B) "It promotes responsibility for your own care." C) "We're setting limits on behavior." D) "It helps you develop a trusting relationship."
A student asks why some vaccinations are given orally and some are given by injection. What response by the professor is best?
a. Different routes allow the speed of onset of the antigen to be varied, with the intravenous route being the fastest. b. Some individuals appear to be unable to respond to an antigen by a specific route, thus requiring the availability of different routes for the same antigen. c. Antigen-presenting cells are highly specialized and thus require stimulation by different routes. d. Each route stimulates a different lymphocyte-containing tissue, resulting in different types of cellular and humoral immunity.