A patient has suddenly become very ill, and a nurse is transferring him to the intensive care unit (ICU). How does the nurse provide information to ensure continuity of care?
A) by giving a verbal report to nurses in the ICU
B) by ensuring that the chart and all belongings are moved
C) by delegating a nursing assistant to provide information
D) by asking the family to provide the information
A
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An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first?
a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.
The nurse assesses a male resident in a nursing home for urinary incontinence and determines that he is unaware of the problem. Which recommendation should the nurse implement?
a. Limit oral fluid in-take. c. Apply absorbent undergarment. b. Provide regular toi-leting. d. Encourage frequent rest periods.
The nurse collecting tissue for a Tzanck smear will (place the steps in sequence):
1. open the lesion with a hypodermic needle. 2. place the specimen in culture tube and take to the laboratory. 3. saturate the sterile swab with exudates. 4. wash the lesion. 5. place a pressure dressing on the lesion.
A patient received a tuberculosis skin test injection of purified protein derivative (PPD) 72 hours ago. Which assessment finding of the test site does the nurse interpret as a positive reaction?
a. The injected area has a blister-like swelling about 2 mm high and 2 mm in di-ameter. b. The injection site is puffy and soft with pus oozing from the needle hole. c. The skin is red and very hard for 12 mm around the injection site. d. There is a large bruise surrounding the injection site.