The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse?
a. "My back is killing me!"
b. "There is blood on my toothbrush!"
c. "Look at the bruises on my arms!"
d. "My arm is bleeding where my IV is!"
A
The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. Severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies must be discontinued, and volume expanders or coagulation factors, or both, are administered.
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County Hospital has position descriptions for all staff, including RN Team Leaders
Sarah, a team leader on the rehab unit, assesses the needs of the patients in her area, assesses the skills and backgrounds of each of the individuals on her team, and then assigns and delegates the ap-propriate care provider to each patient and task. Sarah's activity in the example described is termed: a. Passive delegation. b. Passive accountability. c. Active delegation. d. Active responsibility.
During the well-child assessment on a 2-year-old male the nurse notes that the testes are not descended. The nurse would correctly choose which of the following actions?
1. Report the finding to the healthcare provider. 2. Ask the parent if the child has had any surgeries. 3. Proceed with palpation of the scrotum. 4. Inquire about the child's voiding patterns.
The nurse is implementing nutritional changes to reduce the risk for skin breakdown in a client with impaired physical mobility. Which dietary modifications will the nurse reinforce? (Select all that apply.)
a. High-protein b. Low-protein c. High-carbohydrate d. Low-carbohydrate e. High-fat f. Low-fat
Mr. Sangha emigrated from India 20 years ago and sponsored his father and mother to come to the United States 14 years ago
One of Mr. Sangha's major stressors is liaising between his children, who have become "Americanized," and his parents, who have been minimally influenced by American culture. What term best describes this process of cultural change and adaptation? A) Transculturalization B) Cultural shift C) Acculturation D) Ethnodynamism