Which of the following would be considered a failure of proper implementation?
a. Not identifying and analyzing symptoms appropriately
b. Not documenting the patient's response to pain medication
c. Not recognizing a malfunctioning chest tube
d. Not asking the patient about code or no code wishes
B
Nurses caring for acutely and critically ill patients are required not only to take appropriate action but also to accurately document their findings, interventions performed, and patients' response to those interventions. Failure to thoroughly and accurately document any aspect of care gives rise to negligence causes of action.
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A collaborative problem in caring for patients with COPD includes the potential for respiratory failure. An important indicator on an arterial blood gas (ABG) analysis that respiratory failure is occurring includes which of the following?
A) O2 saturation of 95% B) pH of 7.36 C) HCO3 of 24 mEq/L D) PaCO2 of 70 mm Hg
Which of the nurse's following questions is most appropriate for providing reality orientation for a patient with stage 5 Alzheimer's disease?
A) "Are you looking forward to Thanksgiving next week Mr. Hall?" B) "Could you tell me the month and the year this morning, Mr. Hall?" C) "Do you know what holiday is coming up soon, Mr. Hall?" D) "Will your son and daughter-in-law be coming to visit on Thanksgiving, Mr. Hall?"
Which client has the priority need for fetal monitoring?
a. Primigravida at 38 weeks with spontaneous ROM b. Multigravida at 40 weeks with history of 10-hour labors c. Multigravida admitted for repeat elective cesarean section d. Primigravida at 39 weeks with meconium-stained amniotic fluid
The clinic nurse sees a patient with a long-standing diagnosis of pedophilia who was recently arrested and released on bail. Which perspective about pedophilia would the nurse expect from this patient?
a. Extreme remorse for traumatizing a child to meet his/her own needs. b. Desire to be placed in jail to prevent acting on the sexual impulses. c. The belief that the child was given valuable knowledge and pleasure. d. A feeling of victimization related to genetic and environmental factors.