A nurse believes a new mouth care procedure (MCP) is causing more mouth problems than it is helping to avoid. Which of the following must be present for the nurse to go to administration
with confidence that the new mouth care procedure (MCP) is causing problems? (Select all that apply.)
a. A plausible explanation of how the new MCP could cause harm
b. A strong feeling that the MCP is the cause
c. Consistently seeing mouth inflammation in many of the patients who have received the MCP
d. Documentation from patient records that mouth inflammation in clients did not occur until after the new procedure was implemented
ANS: A, C, D
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An 11-year-old girl is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which parental statement helps the nurse evaluate that teaching is successful?
a. "Our daughter can still be involved in gymnastics." b. "When our daughter's hemoglobin falls below 3.5, she'll need blood." c. "Our daughter will need genetic counsel-ing before she marries." d. "Our daughter should avoid drugs con-taining sulfonamides."
The results of a total serum bilirubin test done on an infant at 52 hours old is 14 milligrams per deciliter. What is the most appropriate initial nursing action?
a. Contact the physician promptly for further orders. b. Prepare for immediate exchange transfusion. c. Discontinue breastfeeding, and start soy-based formula. d. Repeat the test for clarification.
The client is scheduled for a prostatectomy for benign prostatic hypertrophy. On the morning of surgery, the laboratory report on the client's urine indicates the presence of red blood cells, white blood cells, and bacteria
What is the nurse's best action? A. Document the report as the only action. B. Remove the Foley catheter. C. Strain the client's urine. D. Notify the physician.
A patient waiting to have a skin biopsy asks what occurs during the procedure. What should the nurse respond to this patient?
1. "Didn't your doctor tell you?" 2. "Maybe you shouldn't have it done." 3. "I'm not sure." 4. "Let me check to see exactly what you are having done and then we can talk more about what you can expect."