A nurse determines that chest pain is originating from pericarditis rather than angina when the client states:
a. "No, I have not done anything to strain chest muscles."
b. "If I take a deep breath, the pain gets much worse."
c. "This pain feels like there's an elephant sitting on my chest."
d. "Whenever this pain happens, it goes right away if I lie down."
ANS: B
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Which situations are examples of the nurse directing rather than delegating? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. A nurse manager asks a staff nurse to participate in a standing hospital committee. 2. A staff nurse asks the assistant to sit with the roommate of a client who has just died. 3. During a code blue situation, a nurse tells another nurse to start an IV. 4. A nurse tells an assistant to move a client into the hallway during severe weather. 5. A nurse reminds assistants of standard protocol for evacuation in case of fire.
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first?
a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.
A patient who has a wound infection after major surgery has only been taking in about 50% to 75% of the ordered meals and states, "Nothing on the menu really appeals to me." Which action by the nurse will be most effective in improving the patient's oral intake:
a) Make a referral to the dietician b) Have family members bring in favorite foods from home
What are nurse-patient interactions dependent on?
A) The knowledge of patient tendencies during illness B) The nurse's ability to work with a multicultural health care team C) The ability to understand and be understood D) Cultural diversity among the unit staff