When performing Leopold's maneuver, the nurse performs which of the following steps, in what order?
A) Grasp the abdomen just above the symphysis pubis with the thumb to determine fetal part lying in pelvic inlet. B) Palpate the fundus with two hands, and feel for fetal body parts. C) Locate the prominence of the fetal head. D) Using firm-but-gentle pressure, explore one side of the abdomen and then the other for the fetal back.
A
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After shift report, the nurse is preparing to provide morning care to the assigned clients. Which of the following would be the nursing priority when planning care for the client assignment?
1. Gather all equipment and supplies for each client first. 2. Delegate the bed making to the unlicensed assistive personnel. 3. Assess each client's need for assistance with morning care. 4. Notify each client of the schedule for AM care.
The PACU nurse is informed that the client being admitted has not recovered his pharyngeal reflex. The nursing action that should receive greatest priority is to
a. check for the gag reflex frequently. b. maintain an oral airway. c. remain with the client at all times. d. suction the client frequently.
A client of American Indian descent suffers a massive cerebral hemorrhage and is not expected to survive
Which of the following interventions by the nursing staff would be appropriate when attempting to observe this client's religious and cultural traditions? 1. Provide the family's spiritual healer with privacy for death rituals. 2. Offer the family unlimited access to their dying family member. 3. Discuss the possibility of transferring the client home for the death. 4. Make it possible for the family to assist in the care of the dying family member.
Which statement is the best example of nursing outcomes for a cardiac patient who has been
experiencing angina that are consistent with nursing reflective reasoning? A) The patient follows the medical protocol prescribed by the physician. B) The patient has reduced stress levels successfully. C) The patient maintains blood pressure and pulse within normal limits. D) The patient does not experience chest pain.