Appropriate preventive measures for the nurse to take to prevent circulatory overload include:(Select all that apply)
1. Practice consistent hand hygiene
2. Monitor infusions frequently
3. Ensure sterile dressing to insertion site
4. Monitor insertion site routinely
5. Make accurate fluid calculations
5
Rationale: Consistent hand hygiene is appropriate prevention for septicemia, bacteremia
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A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?
a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown
The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. The most effective initial treatment of bleeding is to:
a. elevate the head. b. apply direct pressure. c. apply an ice pack. d. apply indirect pressure.
In developing an orientation program, the hospital educator breaks essential organizational information down into chunks, which she develops as online modules. This is an application of which of Drucker's functions of management?
a. Establishment of goals and objectives b. Motivation and communication c. Analysis and interpretation of perfor-mance d. Organization of activities into manageable tasks
The patient's initial vital signs immediately on return from surgery are BP, 140/90; P, 80; R, 14; T, 98° F. One hour later the vital signs are BP, 130/84; P, 72; R, 16; T, 96.8° F. Based on these assessments, the nurse should:
a. add a blanket for warmth to the patient. b. notify the charge nurse of probable he-morrhage. c. raise the head of the bed 45 degrees. d. note the assessment as normal postopera-tive recovery.