The nurse is caring for a female patient who has undergone a total hip replacement. The patient states she feels an increase in pain at the surgical site after being repositioned in bed
The most appropriate intervention the nurse should make first is:
A) Assess for abnormal external rotation of the leg.
B) Raise the head of the bed.
C) Adjust the hip pillow.
D) Assess for lengthening of the leg.
Ans: A
Feedback: The most appropriate action for the nurse to take includes assessing for other signs of hip dislocation, such as abnormal external or internal rotation of the hip, shortening of the affected leg, and restricted ability or inability to move the leg.
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The nurse is using a family interpreter to teach home care to the deaf parents of a child with cystic fibrosis. Which of the following techniques of working with an interpreter is unique to this situation?
A) Ensuring the parents can read printed material B) Using the child's older sister as interpreter C) Allowing time for interpretation and response D) Expecting the interpreter to know the medical terms
What determinants form the boundaries for nursing roles? (Select all that apply.)
1. Education and licensure 2. Nursing practice 3. Standards of nursing practice 4. Nurse practice acts 5. Codes of ethics
A patient with a terminal illness does not have a do-not-resuscitate (DNR) order, and upon entering the room, a nurse finds that the patient is not breathing. The first action that the nurse will take is to
1. Ask another nurse to write the order for a DNR. 2. Call the physician to get an order for a DNR. 3. Begin cardiopulmonary resuscitation (CPR) because an order for a DNR is not written. 4. Notify the selected funeral home that the patient has expired.
The basic building blocks of nursing, the steps of the nursing process, are similar to the process used in policy making. In what step of the nursing process would the budget be established for a policy that is being developed?
A) Assessment B) Diagnosis C) Planning D) Implementation