A 42-year-old postoperative patient reports falling in the bathroom. The incident report the nurse files needs to include: Standard Text: Select all that apply
1. Client name and hospital or identification number.
2. Date, time, and place of incident.
3. Conclusions based on client's report.
4. Identification of witnesses to the incident.
5. Asking the charge nurse to fill out a report.
1,2,4
Rationale 1: Client name, hospital or identification number, initials
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A child has an invasive intracranial pressure monitoring device in place. Which assessment finding indicates that goals for a priority nursing diagnosis have been met?
A. Daily weight equals admission weight. B. Joints move freely during range of motion. C. No signs of infection are present at the insertion site. D. Skin is intact without redness or breakdown.
The nurse is performing a physical assessment of the client. Which of the following pieces of information are examples of objective data? Standard Text: Select all that apply
1. Apical pulse is 94 beats per minute. 2. Blood pressure in right arm is 118/74. 3. The client has a nonproductive cough. 4. The client reports that his pain is severe and throbbing. 5. Respiratory rate is 18 breaths per minute.
Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies?
a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."
An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take?
a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.