A friend brings a teenager to the emergency department. The friend found the patient unconscious in a bedroom at a party. Semen is observed on the patient's underclothes. Priority actions by the nurse should focus on:
a. preserving rape evidence.
b. maintaining the patient's airway.
c. obtaining a description of the rape.
d. determining what drugs were ingested.
B
Because the patient is unconscious, the risk for airway obstruction is present. The distracters are of lower priority than preserving physiological functioning.
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A new father begins to hyperventilate as his baby is about to be born; he becomes light headed. The nurse instructs him to breathe into the paper bag until his breathing slows down
When he feels better he asks the nurse why using the paper bag helped him. What is the nurse's best response? "Breathing into the paper bag allowed you to a. Rebreathe carbon dioxide to correct respiratory alkalosis" b. Reduce carbon dioxide to correct respiratory acidosis" c. Rebreathe carbon dioxide to correct metabolic alkalosis" d. Reduce carbon dioxide to correct metabolic acidosis"
A patient tells the nurse that he had money in the top drawer of his bedside table that is now missing. He is phoning his attorney and plans to press charges
The nurse realizes this patient is planning to implement which of the following types of law? 1. Criminal 2. Tort 3. Common 4. Contract
A nurse is completing a case management advocacy activity which corresponds to the implementation phase of the nursing process. Which of the following activities would the nurse most likely use?
a. Asking the client what is most important b. Seeking appropriate referrals for the client c. Assuring the client that his wishes will be supported d. Determining the order in which actions will occur
The nurse prepares a 70-year-old client to begin hemodialysis. Before beginning treatment, which of the following immunizations is required?
A) Influenza B) Hepatitis A C) Hepatitis B D) Tetanus and diphtheria