Of the following nursing assessments, which should be reported to the primary care provider immediately by the nurse?
a. Bloody drainage from a patient with a hemothorax
b. Subcutaneous emphysema is noted on assessment
c. Bubbling in the water seal stops on a patient with a pneumothorax
d. Over 300 mL of drainage has been collected in the system in the past hour
D
Drainage exceeding 100 mL/hr should be reported immediately because this would be considered abnormal. Drainage would be expected to be bloody if the patient has a hemothorax. Cessation of bubbling in the water seal indicates that the air has been evacuated in the patient with a pneumothorax. Although the finding of subcutaneous emphysema should be reported, documented, and monitored, it is not an emergency.
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An osteoporosis-related fall necessitated hip replacement surgery for an older female adult who is entering a rehabilitation facility. Which is the nurse's priority goal during this woman's rehabilitation?
a. Eat whole grains, fruits, and vegetables. b. Recapture preoperative mobility status. c. Keep the surgical wound clean and dry. d. Tell her to take two steps into the walker.
A nurse is a member of a committee assigned to review the roles and responsibilities of the nurses on the psychiatric unit. Which publication will the nurse bring to the first meeting?
1. Diagnostic and Statistical Manual of Mental Disorders 2. American Nurses Credentialing Center certification requirements 3. American Nurses Association, Code of Ethics 4. Psychiatric-Mental Health Nursing Standards of Practice
A client has respiratory acidosis. The nurse evaluates that treatment is being effective with which arterial blood gas values?
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A nurse is caring for four patients. The nurse would be concerned about which patient developing a substance use disorder?
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