When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse's priority action?
A. Administer oxygen.
B. Notify the physician.
C. Rapidly administer more IV fluid.
D. Reposition the patient to the right side.
Answer: A. Administer oxygen.
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You are caring for 35-year-old man who tells you that he feels distress about being a male, and ever since he was a young child has thought of himself as a female
He describes the isolation he feels and concern about fitting in socially and at work because of these recurrent thoughts. How would you respond to your patient? 1) Provide information about support groups and other community resources for transsexual people. 2) Reassure him that he is normal, saying there are more people than we know who feel this way. 3) Share with him that you personally have had thoughts like this but have coped with these thoughts. 4) Suggest your patient seeks mental health care for medication to help him deal with his anxiety.
When moving a person in segments, what do you move first?
a. The legs and feet b. The middle of the body c. The upper part of the body d. The head
Which of the following nursing assessment data best reflects the successful achievement of the dying client's right to be pain free?
1. Introducing the client to effective alternative pain management techniques 2. Educating the client on the appropriate use of a patient-controlled analgesia de-vice 3. Pain rated as a 3 out of 10 after the administration of the prescribed pain medica-tion 4. Informed the primary care provider of the client's need for additional pain medi-cation.
The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse take to minimize skin breakdown?
a. Encouraging the patient to bathe before surgery b. Securing attachments to the operating table with foam padding c. Periodically adjusting the patient during the surgical procedure d. Measuring the time a patient is in one position during surgery