The perinatal nurse observes the placental inspection by the health-care provider after birth. This examination may help to determine whether an abruption has occurred prior to or during labor
Indicate whether the statement is true or false.
ANS: True
Fifty percent of abruptions occur before labor and after the 30th week, 15% occur during labor, and 30% are identified only upon inspection of the placenta after delivery.
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A patient in the intensive care unit has a pulmonary artery catheter for hemodynamic monitoring. On assessment, the nurse finds the patient clinically unchanged from the last assessment, but the hemodynamic data are significantly changed
Which action by the nurse is the most appropriate? A. Document the findings and continue to monitor. B. Level and recalibrate the hemodynamic line. C. Notify the health-care provider of the findings. D. Review the last set of laboratory data for any changes.
A client tells the nurse, "You know I have AIDS. I still cannot afford to tell my employer because they will probably cancel my health insurance, then what would I do?" What is the best response by the nurse?
A) "An employer cannot cancel your currently active health insurance on the basis of AIDS." B) "I just wouldn't tell them. It is none of their business." C) "You have to tell them, it is not your right to allow them exposure to you. What if you give it to someone?" D) "I understand your dilemma, but I think you should tell them. I would want to know."
A patient with ARDS is on a mechanical ventilator and is becoming increasingly restless with a heart rate of 128
The SaO2 is 88% and the ventilator settings are FiO2 50%; PEEP 8 cm; AC 10 with a total respiratory rate of 30; and a tidal volume of 700 mL. There are coarse rhonchi audible in all lung fields. The appropriate nursing action would be to: 1. Hyperoxygenate with 100% oxygen and suction the patient. 2. Administer the ordered neuromuscular blockade medications. 3. Increase the FiO2 to 60% and tidal volume to 750 mL for 2 minutes. 4. Increase the PEEP to 10 cm and sedate the patient.
Which of the following is the essential component the nurse must bring to the therapeutic nurse-client relationship?
A) Confrontation B) Empathy C) Humor D) Reframing