A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action?
1. Take vital signs.
2. Establish an intravenous line.
3. Perform rapid neurologic assessment.
4. Maintain patent airway.
4
Explanation:
1. Taking vital signs is important, but airway always comes first.
2. Once the airway is secure, securing an IV is vital.
3. A rapid neurologic assessment is appropriate once the airway is secure.
4. Airway is always the priority of care.
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A metabolic problem often seen in early septic shock is
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The preceptor is working with a new nurse to provide care for a patient with a new tracheostomy
Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.) a. The outer cannula is cleaned with the brush and half-strength H2O2. b. The new tracheostomy holder is secured before the old soiled one is removed. c. A Yankauer suction catheter is used to remove secretions from the patient's mouth. d. Sterile gloves are applied before the soiled dressing is removed from the tracheostomy. e. Half-strength H2O2 is used to remove crusted secretions around the tracheostomy site. f. Pain medication is administered to the patient prior to suctioning.
Which most therapeutic response to the client's statement, "I'm afraid to have a cesarean birth" should be made by the nurse?
a. "Everything will be OK." b. "Don't worry about it. It will be over soon." c. "What concerns you most about a cesarean birth?" d. "The physician will be in later and you can talk to him."