An individual with injuries sustained in a natural gas explosion is unable to respond to questions and keeps repeating "I can't hear." For what should the nurse assess this patient?
A. Tympanic membrane rupture
B. Air embolism
C. Confusion
D. Oxygen saturation level
Answer: A
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A nurse administers a double dose of medication to a client because the physician order was unclear. The nurse is at risk for legal liability on which of the following grounds?
1. failure to ensure safety 2. improper implementation of skills and procedures 3. medication error 4. failure to monitor and assess
When providing education for a client newly diagnosised with mild Alzheimer's disease (AD) and his family, the nurse identifies which of the following as signs that the disease is progressing in severity? Select all that apply
1. Repetitively allows pots of water to boil dry 2. Claims that the newspaper is not readable anymore 3. Becomes agitated when old friends come to visit 4. Develops a ravenous appetite, especially for carbohydrates 5. Is obsessive about how personal belongings are organized
The physician orders fosphenytoin (Cerebyx), 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse?
a. Contact the admitting physician. b. Administer drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.
A nurse is planning to present a lecture/discussion on health maintenance to adolescents in their high school health class. The nurse will include which topic in the presentation information?
1. Limiting refined sugar and high-fat intake 2. Resources for treatment of eating disorders for all adolescents 3. Type 2 diabetes mellitus and insulin resistance 4. The importance of decreasing calcium intake once full adult height is achieved