Which of the following statements accurately describe a recommended guideline for implementation? Select all that apply
A) When implementing nursing care, remember to act independently, regardless of the wishes of the patient/family.
B) Before implementing any nursing action, reassess the patient to determine whether the action is still needed.
C) Assume that the nursing intervention selected is the best of all possible alternatives.
D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful.
E) Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.
F) Check to make sure that the nursing interventions selected are consistent with standards of care.
B, D, F
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Which of the following is an example of clarifying a client's verbal response?
1. "Are you saying you feel the medicine is helping you?" 2. "See, the medicine does work." 3. "I knew it would work; it just takes time." 4. "Everything seems to work out eventually."
A male client asks, "Why do I have to use another contraceptive? I had a vasectomy last week." The best response is:
a. "A vasectomy is only 85% effective." b. "A vasectomy is not effective in all men." c. "Semen may contain sperm for 6 months following a vasectomy." d. "Complete sterilization doesn't occur until all sperm have left the system."
A patient with liver failure has been on the transplant waiting list for 8 months. The patient says to the nurse, "Why is it taking so long to have the surgery? Maybe I'm meant to die for all the bad things I've done."
The nurse should document the patient's comment in which section of the assessment? a. Physical b. Spiritual c. Financial d. Psychological
A child in decompensated shock with hypotension should:
A) be intubated to protect his or her airway. B) receive initial fluid resuscitation at the scene. C) be given 25% dextrose to prevent hypoglycemia. D) receive volume expansion with 5% dextrose in water.