The nurse is caring for a client diagnosed with breast cancer, who underwent a left-sided mastectomy two days prior. The nurse has delegated vital signs on this client to the patient care assistant (PCA)
What specific instructions should the nurse provide to the (PCA) in delegating this task? 1. Take the blood pressure on the right arm.
2. No special instructions are needed.
3. Take the blood pressure on the left arm.
4. Take the blood pressure on both arms for a baseline.
1
Rationale 1: The blood pressure should be taken in the arm opposite the surgical site. Blood pressures should not be taken on the same side as a mastectomy. It should also not be taken on an arm with a shunt, trauma, or disease. If this is not possible, then a thigh pressure should be obtained.
Rationale 2: The nurse should be sure to provide the PCA with instructions to use the arm opposite the surgical site for blood pressure readings.
Rationale 3: The left arm should not be used for blood pressure readings, intravenous fluids, or other invasive procedures.
Rationale 4: It is not possible to take the blood pressure using both arms, since the left arm should never be used again for blood pressure readings. If bilateral readings become necessary, the thighs should be used so that a comparison can be made.
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The nurse working at the bedside traditionally participates in which advocacy role? (Select all that apply.)
1. Legal 2. Self 3. Collective 4. Class 5. Citizen
A nurse manager in a trauma intensive care unit conducts a quality improvement evaluation project
During this process, she discovers that patients with adult respiratory distress syndrome almost always have better outcomes when they are placed in the five beds located further away from the nursing station. Examining the data, she discovers that the room doors in these five rooms are consistently half-closed or three-quarters closed. In addition, nurses have been documenting that these patients sleep more than the other ten patients on the unit. What are the nurse's options for generalizing the findings? a. There is no practical use for this research; no generalization is appropriate. b. Findings should be generalized immediately, and in print. These are important findings. c. The nurse can present the findings at conferences, but generalization is limited to the hospital in which the data were collected. d. The nurse manager can obtain permission from an institutional review board to conduct a formal research study, in order to formally test hypotheses, and then generalize the findings of this second study. e. Arrangements should be made immediately on the unit to keep all patients' doors half-closed or three-quarters closed.
Which statement about drug therapy for heart failure is true?
a. The drugs work only directly on the heart muscle. b. Drug therapy improves heart function but does not cure heart failure. c. When heart function returns to normal, the drug therapy can be stopped. d. Drug therapy for heart failure does not work when the patient continues to smoke.
Jane Doe was given Tylenol for her fever at 8 a.m. At noon, her temperature was 39.2°C. What action should be taken at noon? 
A. Administer one 325 mg Tylenol tablet. B. Administer one-half 325 mg Tylenol tablet. C. Do not administer Tylenol; her temperature is below 101°F. D. Administer two 325 mg Tylenol tablets.