The nurse is triaging victims of a human-made disaster. When caring for these clients, the nurse should do which of the following?
a. Provide optimal service for each client.
b. Transport clients to areas with electricity and water.
c. Be concerned with personal safety first.
d. Maintain infection control interventions.
ANS: D
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The baseline fetal heart rate is 135. Thirty seconds after the onset of a contraction, the heart rate begins to slow; after the peak of the contraction, the heart rate is 110; thirty seconds after completion of the contraction, the heart rate is
back to 135. Which nursing action is most important? 1. Assist the client to change from Fowler's to left lateral position. 2. Document the fetal heart rate. 3. Apply oxygen via mask at 10 liters. 4. Check the cervix for labor progress.
A 77-year-old woman who is 5 feet 3 inches tall and weighs 89 lbs has been admitted to the hospital with a diagnosis of failure to thrive. What action should the nurse prioritize when addressing the woman's apparent lack of nutrition?
A) Assess the reasons behind the patient's poor nutritional status B) Educate the woman about the importance of balanced nutritional intake C) Order double meal trays for the woman for the duration of her hospital stay D) Create incentives for the woman to increase her food intake
A 2-year-old girl has had repeated ear and upper respiratory infections since she was born. A pediatrician has determined a diagnosis of transient hypogammaglobulinemia of infancy. What is the physiological origin of the child's recurrent infections?
A) The child's immune system is unable to synthesize adequate immunoglobulin on its own. B) The child had a congenital absence of IgG antibodies that her body is only slowly beginning to produce independently. C) The child was born with IgA and IgM antibodies, suggesting intrauterine infection. D) The child lacks the antigen-presenting cells integral to normal B-cell antibody production.
After administering a decongestant, which of the following would the nurse include in the ongoing assessment? Select all that apply
A) Heart sounds B) Blood pressure C) Level of congestion D) Therapeutic effect E) Pain assessment