After obtaining a full set of vital signs, the nurse assesses the client's fifth vital sign as a 7 on a scale of 1 to 10 (or 7/10). Which action by the nurse is most appropriate?
a. Document the pulse pressure as normal and continue the client's assessment.
b. Review the client's records to determine the last time he received pain medication.
c. Assess the client's pulse on the opposite side for comparison.
d. Wait 2 minutes and retake the client's blood pressure.
ANS: B
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The nurse is completing a morning assessment on an older adult Asian client. Assessment findings reveal circular red welts over the client's upper back with several bruised areas. Which nursing action is the most appropriate?
A) Contact adult protective services. B) Call the healthcare provider immediately. C) Assess the client's spiritual beliefs. D) Contact the client's family.
The ANA's Code of Ethics for Nurses is used to provide specific advice involving which of the following (select all that apply)?
a. How to document a patient fall b. Decisions about a patient's right to die c. How to handle impaired nursing practice d. Chain of command when a physician does not return pages e. Handling situations where a client's needs are beyond the scope of nursing compe-tency
The patient with hyperthyroidism is undergoing ablation therapy with radioactive iodine. The precaution the nurse will employ is to:
a. take radioactive precautions with syringes and bedpans. b. use Standard Precautions only. c. enforce isolation for 3 days. d. wear a mask and eye protectors when caring for patient.
To prepare a pediatric dosage, the nurse needs to determine the child's weight in kilograms. The child who weighs 54 lb weighs approximately:
A. 25 kg B. 27 kg C. 54 kg D. 119 kg