The nurse is caring for a client who is suspected of having a rupturing abdominal aortic aneurysm. What manifestations are consistent with early onset of the phenomena? Select all that apply
A) elevated temperature
B) complaints of leg pain
C) abdominal pain
D) low back pain
E) pulsating, palpable abdominal mass
Ans: C, D, E
Feedback:
Abdominal or low back pain may signal the beginning of rupture. Sudden severe back pain, shock, and pulsatile, palpable abdominal mass are classic symptoms during rupture.
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A nursing manager wants the unit's staff to consistently use evidence-based practices (EBP). What rationale does the manager give for desiring this practice? (Select all that apply.)
a. Better patient outcomes b. Decreased health care costs c. Enhanced work satisfaction d. Improved quality of care e. Increased intraprofessional communication
The RN and nursing assistive personnel (NAP) are caring for six patients on the pulmonary unit. Which of the following tasks would be most appropriate for the nurse to delegate to the NAP?
a. Taking vital signs on a 56-year-old man with severe dyspnea b. Suctioning a patient with hemoptysis c. Encouraging a postoperative patient to use the incentive spirometer d. Performing chest percussion on a patient with atelectasis
A nurse is preparing a teaching plan for a patient with HIV who has been diagnosed with microsporidiosis. Which implementation should be included?
a. Drink 3 quarts of fluid a day to combat dehydration. b. Include milk products with every meal. c. Consume liberal amounts of fat for in-creased energy. d. Limit protein intake to reduce serum am-monia levels.
An LPN/LVN demonstrates to a new mother how to safely bathe her infant. This is an example of the phase of the nursing process called
a. assessment. b. nursing diagnosis. c. planning. d. implementation.