Which nursing action can be categorized as a surveillance or monitoring intervention?
A) auscultating of bilateral lung sounds
B) providing hygiene
C) administering paracetamol tablet
D) use of therapeutic communication skills
Ans: A
Feedback:
Surveillance or monitoring nursing interventions includes detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the physician to minimize problems.
You might also like to view...
Which of the following interventions would help minimize disorientation for a hospitalized older person?
a. Having multiple caregivers to give the older person a feeling of security by having many individuals caring for him b. Keeping the television on all day and night to provide diversion c. Waking the older person every 2 hours to orient him or her to the surroundings d. Allowing the older person to bring small, familiar objects to the hospital
The preceptor nurse delegates a complex nursing procedure to a newly licensed nurse. The new nurse makes an error, which results in the patient's death. Does the preceptor hold any liability in this case?
1. No, since the new nurse is employed by the medical facility, all liability is corporate. 2. Yes, the preceptor is responsible for delegating appropriately and supervising completion of tasks. 3. No, since the new nurse has a license, all liability is retained by the new nurse. 4. Yes, but only because the event resulted in patient demise.
A nurse is working with a patient who was diagnosed with type 2 diabetes 4 months ago. The patient's blood sugars have stayed under control. What action by the nurse is best?
a. Ask the patient what barriers to wellness still exist. b. Remind the patient about the A1C in 2 months. c. Review side effects of medications with the patient. d. Ask the patient how she or he feels about diabetes.
A patient diagnosed with an eating disorder refuses to be weighed and says, "I just drank a big glass of water." Select the nurse's best response
a. "Call me after you have emptied your bladder." b. "This is weight day. Please step on the scale." c. "I will weigh you tomorrow." d. "You know the rules."