One of your measurements yields a reading during physical assessment that seems very doubtful, considering the patient's general condition. If you are still in doubt about the data after rechecking, your best option is to
a. discard the instrument.
b. record the initial reading.
c. discard the reading and go on to the next assessment.
d. seek another qualified nurse to confirm the reading.
D
Always verify assessment data that are extreme. Double-check the findings. If there is still doubt, ask another qualified nurse to assess the measurement and confirm the reading. If several qualified nurses obtain the same results using the same instrument, then consider that the problem may be the instrument. A different machine may need to be obtained. If the initial reading is extreme, it would be inappropriate to record it. Option "c" is also not an appropriate nursing action.
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The nurse is providing care to a patient who has just undergone an electrophysiologic (EP) study. The patient states that she is nervous about "things going wrong" during the procedure. What is the nurse's best response?
A) "This is basically a risk-free procedure." B) "Thousands of patients undergo EP every year." C) "Remember that this is a step that will bring you closer to enjoying good health." D) "The whole team will be monitoring you very closely for the entire procedure."
A patient with insomnia reports taking diazepam (Valium) and wine in increasing amounts to be able to sleep. The nurse should teach the patient about
a. dangers of central nervous system (CNS) depression. b. risks of acetaldehyde toxicity. c. risks of fetal alcohol syndrome. d. diazepam and dietary precautions.
Your client has a fractured hip as a result of a fall. What nursing diagnosis would be most appropriate?
1. Impaired physical mobility 2. Acute pain 3. Activity intolerance 4. Risk for injury
During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing action is:
a. To notify the patient's midwife or physician b. Massage the fundus until firm and reevaluate within 30 minutes c. Give Syntocinon as per orders d. Assist the patient to the bathroom and ask her to void