The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse pressing the discharge button?
A) Placing gel on the chest
B) Checking the ECG rhythm
C) Shouts, "All clear"
D) States, "Charging"
C
Feedback:
Preceding pressing the discharge button, the nurse shouts "All clear" to ensure that no one is in contact with the client. The other options are correct but not the nursing action immediately preceding.
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Goals are broad statements of purpose that describe the aim of nursing care. As such, goals:
a. are considered short term if achieved within a month of identification. b. always have established time parameters, such as "long-term" or "short-term." c. are mutually acceptable to the nurse, patient, and family. d. can be vague to facilitate evaluation of achievement.
Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?
a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene)
The nurse is preparing to administer a second dose of diphtheria-pertussis-tetanus (DPT) when the parent expresses concern that their child developed a red rash after the previous diphtheria-pertussis-tetanus (DPT) immunization. Which action should the nurse take?
A. Administer only a pertussis-tetanus immunization. B. Withhold this immunization and contact the healthcare provider. C. Instruct the parent to give the child acetaminophen (Tylenol) if another rash develops. D. Administer diphenhydramine (Benadryl) prior to the diphtheria-pertussis-tetanus (DPT) immunization.
Which statement reflects correct cardiac physical assessment technique?
A. Auscultate the aortic valve in the second intercostal space at the right sternal border. B. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. C. Palpate the apical pulse over the third intercostal space in the midclavicular line. D. Assess for carotid bruit by auscultating over the anterior neck.