A nurse recognizes that strategies for clear, accurate communication to promote client safety include which of the following?
a. Establishing a safe environment
b. Maintaining a climate of closed communication
c. Using unique interdisciplinary communication tools
d. Using communication tools that promote vague communication
ANS: A
Clear, accurate communication is the bedrock of safe care. Accurate, clear communication and best practice are indicators of quality of care and serve to maintain a safe environment.
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Which intervention demonstrates effective care for an individual who has expressed a wish to "retire sometime soon"? Select all that apply
a. Asking about when they plan to retire b. Assessing their ability to handle the stresses of retirement c. Engaging them in a conversation about their interests d. Inquiring about the existence of any chronic illnesses e. Scheduling a full physical examination
The healthcare provider prescribes partial weight bearing of the left leg for the postoperative patient. Which instruction should the nurse include in patient teaching?
a. Prevent the left leg from touching the floor at all times. b. Rest the left leg gently on the floor to stand with crutches. c. Distribute weight equally to each leg while crutch walking. d. Step with the left leg first to ascend the stairway with crutches.
The nurse recognizes a generalized tonic-clonic seizure by the client exhibiting what characteristics?
a. rigidity with muscle jerks, temporal apnea, possible loss of bowel and bladder control. b. staring, fluttering eyes, no loss of consciousness. c. blank stare followed by random activity; automatism may be present. d. jerking of one arm, leg, or the face, with altered sense of taste and smell.
The nurse identifies pulsus paradoxus on a patient's arterial pressure waveform monitoring when:
1. The waveform has tall, tented waves. 2. The pulse pressure is above 20 mm Hg on exhalation. 3. There is a decrease of more than 10 mm Hg in the arterial waveform before inhalation. 4. There is a single, nonperfused beat.