The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings reflect the motor response portion of the scale? Select all that apply.
A. Abnormal flexion to pain.
B. No response with eyes to commands.
C. Pupil response sluggish.
D. Abnormal extension to pain.
E. Pupils fixed and dilated.
Answer:
A. Abnormal flexion to pain.
D. Abnormal extension to pain.
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The nurse instructs the patient who is scheduled for thoracic surgery of the importance and techniques for performing incentive spirometry:
A) Prior to surgery B) In the hours immediately following surgery C) 1 day after surgery D) On the day of discharge from the hospital
A nurse is teaching a crutch walking technique that requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. What is the term for this gait?
a. Four-point gait b. Three-point gait c. Two-point gait d. Three-point alternating gait
The nurse receives the report for a client recovering from a repair of a fractured hip, who is being transferred to the orthopedic care area. The following information was obtained in the telephone report:
Report received 14:00 hours: 76-year-old female; ORIF of right hip caused by falling in the home; receiving Morphine sulfate 2 mg IV every 4 to 6 hours for pain; difficult to keep turned on non-operative site; indwelling urinary catheter in place; Hgb 10 after 2 units PRBCs post-operatively. Which National Patient Safety goals should the nurse make a priority for this client? (Select all that apply.) 1. Prevent wrong site/procedure/person surgery. 2. Prevent health-care associated pressure ulcers. 3. Improve the accuracy of patient identification. 4. Reduce the risk of patient harm resulting from falls. 5. Reduce the risk of health care-associated infections.
The RN is in an ideal position to increase quality of care and reduce costs if acting responsibly and accepting accountability for establishing and maintaining the plan of care
Indicate whether the statement is true or false