A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?
a. Facilitate marking the site with the client and surgeon.
b. Have the client mark the operative site.
c. Mark the operative site with a waterproof marker.
d. Tell the surgeon it is time to mark the surgical site.
ANS: A
The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.
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Several nurses at Hospital X are concerned that agency policies related to restraint and seclusion and
documentation practices are inadequate. The understanding about the relation of substandard institutional policies and individual nursing practice that should guide nursing practice is a. the policies do not absolve the individual nurse of the responsibility to practice according to professional standards of nursing care. b. agency policies are considered by the courts to be the legal standard by which the professional nurse must act and therefore override the American Nurses Association standards of care. c. in an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises without delay. d. interpretation by the judicial system will be rendered on an individual basis and therefore cannot be predicted.
What are the criteria for evaluating outcomes during the acute withdrawal phase as achieved? (Mark all that apply.)
A) The client has not relapsed. B) The client has recognized the problem and taken ownership of it. C) The client exhibits no signs or symptoms of substance intoxication. D) The client has sustained no injuries during the detoxification period. E) The client exhibits no signs or symptoms of substance withdrawal.
The double-walled sac that surrounds the heart is called the:
a. endocardium c. myocardium b. epicardium d. pericardium
The nurse enters the room of a patient with a new mastectomy and finds her crying. After confirming that the patient is crying because of the loss of her breast, which response by the nurse is best?
a. "At least they got all the cancer. You are fortunate." b. "I know how you feel. It is difficult to lose a breast." c. "How have you coped with other problems in your life? Do you have someone you can talk to?" d. "Here, have a tissue. I know you feel like crying now, but before you know it, you will feel much better, and this will all be behind you."