A nurse in a local healthcare facility is caring for a client suspected of internal bleeding
Which observation in the client is most essential that the nurse report to a physician?
A) Extreme hunger
B) High blood pressure (BP)
C) Shallow, rapid breathing
D) Slow pulse
C
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The nurse is selected to participate on a committee to write critical pathways for a specific set of medical diagnoses. Which are advantages of using this approach when providing client care?
Select all that apply. A) Link nursing diagnoses with specific assessment data B) Sequence the care that is to be given on a particular day C) Identify interventions, time frames, and expected outcomes D) List medical treatments to be performed by other providers E) Provide specific columns for diagnosis, interventions, and evaluation
During the assessment of the integumentary status the nurse determines that an older client is experiencing age-related skin changes. What did the nurse assess to make this clinical decision? (Select all that apply.)
1. Gray hair 2. Thick yellow peeling nails 3. Ecchymosis over bilateral thighs 4. Pustules on the lower neck region 5. Petechiae scattered over the forearms
A type I diabetic delivers a healthy baby girl by cesarean section for fetal distress. She is one day post-op. Which order should you question?
a. AccuChecks qid; resume last insulin dose prior to delivery b. AccuChecks qid and cover with regular insulin according to sliding scale c. Encourage ambulation d. IV lactated Ringer's @ 125/hr. until tolerating clear liquids
When caring for clients with STDs, the nurse is aware that the best method of infection control is
a. good hand-washing. b. disease-based isolation techniques. c. no extra infection control measures. d. universal precautions.