The nurse is caring for a drowning victim after resuscitation. What focused assessment will the nurse perform to identify complications from drowning?
a. Palpation of abdominal cavity
b. Inspection of skin color
c. Auscultation of lungs
d. Palpation of pulse strength
C
Auscultation of the lungs will assist the nurse to identify complications from drowning, including pulmonary infection and acute respiratory distress syndrome (ARDS). All other assessments are important, but the nurse must focus on the respiratory system as most likely to demonstrate com-plications.
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The nurse recognizes indications of respiratory distress, which include: (Select all that apply.)
a. gasping. b. wheezing. c. stridor. d. choking. e. stupor.
The nurse manager is evaluating the use of evidence-based practice guidelines to guide care on a patient care area. Which observations indicate that these guidelines are being used appropriately?
1. Guidelines are posted on the staff bulletin board in the break room. 2. A guideline was quoted in a narrative note in a patient's medical record. 3. A guideline is placed in the Kardex to support the use of a nursing diagnosis for a patient's health problem. 4. Guidelines are accessed through the clinical documentation system by nurses prior to writing patient care plans. 5. A guideline was referenced prior to implementing skin care interventions for a patient prone to pressure ulcer formation.
A group of nurses have recently been hired at your hospital. Because the nurses are from a different country, they would most likely experience which of the following?
a. Ambivalence c. Hoarding of tradition in ethnic groups b. Improved lifestyle d. Culture shock
The nurse is providing discharge instructions to a patient recovering from a total hip replacement. What should the nurse include in these instructions? Select all that apply.
A. Full recovery in up to six months B. Use and weight bearing of affected limb C. Possible complications such as infection or dislocation D. Continuing pain medications for only two days after discharge E. Not to do exercises if experiencing discomfort