These statements are about the nursing process. Which is correct?
a. It changes as the person's needs change.
b. It never changes.
c. It requires a doctor's order.
d. You are responsible for it.
A
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The nurse is delegating care of a patient with a chronic nonsterile wound to a UAP. The delegation is inappropriate if:
a. the nurse asks the UAP to assess the wound. b. the nurse asks the UAP to report increased wound drainage. c. the nurse asks the UAP to observe changes in dietary intake. d. the nurse asks the UAP to change the dressing.
The goal of treatment of acute pain is:
1. Pain at a tolerable level where the patient may return to activities of daily living 2. Reduction of pain with a minimum of drug adverse effects 3. Reduction or elimination of pain with minimum adverse reactions 4. Adequate pain relief without constipation or nausea from the drugs
The nursing assistive person is taking vital signs and reports that a patient's blood pressure is abnormally low. The nurse should
a. Have the nursing assistive person retake the blood pressure. b. Ignore the report and have it rechecked at the next scheduled time. c. Retake the blood pressure herself and assess the patient's condition. d. Have the nursing assistive person assess the patient's other vital signs.
The nurse assesses a patient and immediately notifies the physician because of findings consistent with a gastrointestinal bleed
What did the nurse assess in the patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Melena 2. Hematemesis 3. Confusion 4. Blood pressure of 180 /100 mm Hg 5. Absent bowel sounds