The nurse caring for a client who had a thyroidectomy earlier today assists the client to roll onto the side to examine for:
1. Wrinkles.
2. Bleeding.
3. Diaphoresis.
4. Bruising.
2
Rationale: The client must be rolled over in order to see if there has been any bleeding because blood will run along the folds of the neck and collect on the bed linen.
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Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old sister in care? (Select all that apply.)
a. She will feel less neglected by the parents. b. She can make amends for past hostilities to her brother. c. She will feel increased helplessness. d. She can express her feelings through care. e. She can experience being supportive of her parents and brother.
The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which of the following laboratory results will the nurse expect to find in the patient's chart?
a. Glycosylated hemoglobin 12% b. Platelet count 450,000/mm3 c. Hematocrit 32% d. Prothrombin time 8.8 seconds
Which data would be of most interest to an organization using Lean Six Sigma as a means of quality improvement?
1. Eighty-five percent of call lights are answered within 4 minutes. 2. Results of pain medication administration are documented 95 percent of the time. 3. Nursing overtime hours increased by 25 percent in the last quarter. 4. In the last 6 months, overall client satisfaction scores have increased by 15 percent.
A preschool child in the emergency department has a respiratory rate of 10 breaths per minute. How should the nurse interpret this finding?
a. The child is relaxed. b. Respiratory failure is likely. c. This child is in respiratory distress. d. The child's condition is improving.