Which of the following client situations should the nurse report to the supervisory RN or physician for further assessment? Select all that apply
A) the client 12 hours after a cesarean section with hypoactive bowel sounds B) the breastfeeding client at 72 hours postpartum with very firm, warm breasts C) the client on IV magnesium sulfate 24 hours after delivery who appears flushed and complains of fatigue D) the client who saturates more than one pad per hour E) the client at 48 hours postpartum who reports pain in one leg when the nurse dorsiflexes the foot
D, E
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An experienced nurse often answers less experienced nurses' questions about client care and teaches hemodynamics during orientation to the unit. The nurse has also participated in research into hemodynamic monitoring of ICU clients
Which clinical ladder designation does this nurse best exemplify? 1. Clinical colleague 2. Clinical mentor 3. Clinical leader 4. Clinical expert
A severely cognitively impaired adult has had a surgical procedure, and the nurse is having a difficult time assessing the level of pain the client is having postoperatively. What method can the nurse use to obtain data about the client's pain?
A) Have the client point to a smiley face or a frown. B) Ask the client to point to a pain level between 0 and 10 on a chart. C) Use behavioral comparison of the client's current and previous behavior patterns. D) Ask the client loudly if he is having any pain and what level it is.
A client is being weaned from total parenteral nutrition to oral intake. Which of the following should the nurse assess in this client?
a. Electrolyte statuser b. Thirst c. Hung d. Muscle weakness
When cleaning a wound, the nurse should:
1. Wash over the wound twice and discard that swab 2. Move from the outer region of the wound toward the center 3. Start at the drainage site and move outward with circular motions 4. Use an antiseptic solution followed by a normal saline rinse