After change-of-shift report, which patient will the nurse assess first?
a. A 40-year-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left
b. A 40-year-old man with continuous enteral feedings who has developed pulmonary crackles
c. A 30-year-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition
d. A 30-year-old woman whose gastrostomy tube is plugged after crushed medications were administered.
b. A 40-year-old man with continuous enteral feedings who has developed pulmonary crackles
The patient data suggest aspiration has occurred and rapid assessment and intervention are needed.
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An elderly male client's wife of 50 years recently died from cancer. He suffers from a chronic debilitating illness and has been refusing to eat, drink, or take his medications. This client is displaying behavior characteristic of:
a. Suicidal threats b. Suicidal attempts c. Suicidal ideation d. Passive suicide
The nurse makes the entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, ‘I am afraid I will fall.'" The most appropriate nursing action is to:
a. notify the physician. b. reconsider the interventions on the care plan. c. reassign the client to another nurse. d. write a new nursing diagnosis.
A child with attention deficit hyperactivity disorder (ADHD) is prescribed methylphenidate hydrochloride (Ritalin). What should the nurse instruct the parents regarding an adverse effect of this medication?
A) Anorexia B) Sleepiness C) Garbled speech D) Rapid increase in height
One school district is not requiring vaccinations for children who are starting school. The nurse realizes that this action could have which consequence?
1. healthier children 2. a reduction in the number of colds and flu in the school 3. lower school costs 4. an epidemic of an illness that could have been avoided with immunization