What immediate actions will you take?
What will be an ideal response?
• Make certain the airway is open and clear. Apply oxygen therapy.
• Elevate the head of the bed 30 to 35 degrees and keep his head in a neutral position.
• Institute ECG and automatic BP monitoring; obtain J.R.'s vital signs.
• Start at least two large-bore IV lines.
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The ultimate goal of The American Association of Critical Care Nurses (AACN) Certification is to
A) increase salaries for certified nurses. B) recognize critical care nurses in the hospital setting. C) differentiate technically skilled nurses from research-based nurses. D) provide optimal care to critically ill patients and their families.
The nurse had been caring for a critically ill patient for several days, and the patient has just died. After completing end-of-life care of the patient and family, the nurse asks to take a short break
What is the best response by the charge nurse? A) Ask the nurse to wait to take a break until after she admits another patient. B) Deny the nurse a break, as the unit is particularly busy and the nurse cannot be spared. C) Arrange for the nurse to have psychological counseling for inability to handle stress. D) Ask another staff nurse to cover this nurse's duties and allow her to take a break.
A nurse taking care of a burn patient is asked why the patient is losing so much weight. What would be the nurse's most appropriate answer?
A) "Your body has built up extra fat deposits even though you haven't been eating very much." B) "Your body has used your fat deposits for fuel because you haven't been eating very much." C) Your reserve fat deposits have been catabolized because you have been eating so much." D) You have lost fluids and you haven't eaten very much."
The nurse has auscultated the patient's heart sounds and has measured vital signs. Which finding would the nurse evaluate as indicating greatest need for additional assessment?
1. Pulse pressure of 38 mm Hg 2. Bounding, vigorous pulse 3. Split of S2 4. Apical pulse of 66