The nurse has just received change-of-shift report about the following four patients. Which patient should be assessed first?
a. A patient with a cervical radium implant in place who is crying in her room
b. A patient who is complaining of 5/10 pain after an abdominal hysterectomy
c. A patient with a possible ectopic pregnancy who is complaining of shoulder pain
d. A patient in the fifteenth week of gestation who has uterine cramping and spotting
ANS: C
The patient with the ectopic pregnancy has symptoms consistent with rupture and needs immediate assessment for signs of hemorrhage and possible transfer to surgery. The other patients should also be assessed as quickly as possible but do not have symptoms of life-threatening complications.
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The couple has had an ultrasound at 19 weeks' gestation, and their fetus was found to have anencephaly. The nurse is completing counseling for the couple on the ultrasound findings
Which statement indicates that additional teaching is needed? 1. "We won't know if something is wrong until the baby's chromosomes are tested." 2. "This problem is not caused by one of us having a genetic problem." 3. "Our baby has an incomplete brain, and might not be born alive." 4. "Waiting until our 30s did not cause this problem to develop."
A child is brought by his parents to the health care center for MMR vaccination. On taking the medical history, the nurse understands that the child had received an antivenin injection for a snake bite 2 days before
Which of the following is the most appropriate time period for administration of live vaccines to the child? A) After 1 to 2 weeks B) After 3 to 4 weeks C) After 4 to 5 weeks D) After 6 to 12 weeks
When you apply sharp and dull stimuli to assess your patient' sensation of superficial pain, the patient reports impaired sensation on the lower left leg
You attempt to define the area of diminished sensation by applying stimuli to that extremity from the a. area of normal sensation to the area of impaired sensation. b. groin toward his foot. c. knee toward his foot. d. area of impaired sensation to the normal area.
The pediatric nurse caring for patients in the pediatric intensive care unit knows that electrolyte measurements, particularly potassium, are perhaps the most critical lab tests in the initial postoperative period
A) True B) False