A client arrives at the healthcare center in a critical state. What step of the nursing process would the nurse have to complete before notifying a physician?
A) Nursing assessment
B) Nursing diagnosis
C) Planning
D) Implementation
A
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The nurse would have to conduct a preliminary assessment of the client by measuring vital signs before reporting the case to the physician. Planning, nursing diagnosis, and implementation come at a later stage during the nursing process.
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a. Nurse sensitive indicators b. Evidence-based practice c. Case management d. Outcomes management
The nurse is assessing a client who has a wound on the left calf. Drainage is coming from the wound. What does the nurse tell the client about this finding?
a. "Exudate or drainage is a natural occur-rence with inflammation." b. "Exudate or drainage means the wound is infected." c. "Drainage from a wound is never a good sign." d. "All wounds result in bleeding and pus formation."
Which of the following is NOT a goal of the initial assessment?
1. identification of contributing factors 2. prevention of disease 3. restoration and rehabilitation 4. identification of how the nurse can help the client
The nurse is caring for a patient who requires continuous electrocardiogram monitoring. Which of the following should the patient's alarms be set to if the patient's normal heart rate is 86 beats per minute?
1. low 66, high 106 2. low 76, high 96 3. low 80, high 100 4. low 60, high 100