In order to protect the airway in a client with a Glasgow Coma Scale score of 3, the nurse collaborates with the health care team to assist with which of the following?
1. Endotracheal intubation
2. Assessment of bowel sounds
3. Monitoring oxygen saturation
4. Questioning the client regarding difficulty breathing
Endotracheal intubation
Rationale: A Glasgow Coma Scale score of 3 indicates a very decreased level of consciousness; the priority is to protect the airway. Bowel sounds may be absent in shock; the ABCs are addressed first. Questioning regarding difficulty breathing is not done because the client is not verbal with a Glasgow Coma Scale score of 3.
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The older adult long-term care resident with dementia becomes agitated each evening after supper because he "hasn't walked his dog
" The nurse plans to intervene by doing the fol-lowing (prioritize these options from the most simple to the most complex): 1. Remind him that his dog is not in the facility. 2. Help him draw a dog on paper and carry it with him. 3. Give him a small stuffed dog. 4. Reorient resident to time and place. 5. Ask his daughter to bring the dog to the facility.
Improper use and care of the glucose meter may result in transfer of bloodborne pathogens.
Answer the following statement true (T) or false (F)
Explain the purpose of the FFP for C.W
What would be an ideal answer?
The following statement appears on a nursing care plan: "Prior to discharge, [Client] will be able to complete wound care without assistance." This statement is an example of a:
1. nursing intervention. 2. nursing diagnosis. 3. client goal. 4. client outcome.