The nurse discovers a patient who is experiencing respiratory distress and mild shock. In which of the following positions should the patient be placed?
a. Semi-Fowler's position
b. High Fowler's position
c. Flat with elevated foot of bed
d. Trendelenburg position
ANS: A
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A client standing in the dining room is experiencing auditory hallucinations commanding him to
strangle someone. His behavior and verbalizations indicate he is experiencing severe to panic level anxiety. Put each of the nursing interventions in the order they should be undertaken. A. Send another staff member to report the situation and obtain a prn medication. B. Assure the client that staff will help him resist the command. C. Take the client to a quiet, secure environment. D. Clear the dining room of other clients. E. Explain that the medication will stop the voices, then administer the drug.
In a rural hospital, the unit for which you are charge nurse has a particularly busy morning. A 52-year-old patient is complaining of left-sided chest pain and a multiparous patient is about to deliver. A child with asthma is experiencing early signs of an attack. The other RN on the unit is a recent graduate who has not yet been orientated to the labor room and has limited cardiac nursing experience. An unregulated assistant is also available. You must decide which patient situation you will take and where the RN's skills can best be used. Given the limitations in skills and experience, number of staff available, and time constraints, you must make a decision that involves:
a. A higher-order thinking process. b. Selecting the best option for reaching a predefined goal. c. Optimizing. d. Satisficing.
A patient is admitted with lower abdominal pain and nausea. The nurse performing the initial assessment notes that the patient's abdomen is distended and firm, and hypoactive bowel sounds are present. The patient has not had a stool for 3 days
The nurse will contact the provider, who will: a. order a bulk-forming laxative. b. order extra fluids and fiber. c. perform diagnostic tests. d. prescribe a cathartic laxative.
Which statement related to delegation is correct?
a. The practice of unlicensed assistive personnel (UAP) is defined in the nurse practice act. b. Nursing practice can be delegated only when the LPN/LVN and/or UAP have received adequate training. c. Supervision is not required when routine tasks are delegated to a competent individual. d. The RN must be knowledgeable about the laws and regulations that govern nursing practice, as well as those that have no clearly defined parameters, such as for UAP.