immobilize the affected shoulder with a sling encourage weight-bearing exercise increase fluids to 1,500 cc/day prepare for surgical repair
The nurse notices an increase in the prevalence of deep vein thrombosis among clients in a surgical unit. The nurse collects data, develops a preventative program with peers, and works with her manager to implement a new policy and procedure. Which of the following best describes the nurse’s actions?
collaboration consultation informatics performance improvement
The ED nurse has triaged a client who was in a severe motor vehicle accident. He is unconscious with fractures to the left femur and left humerus and ulna. CT also reveals a large amount of internal hemorrhaging. No identification was found on the client at the scene. What is the correct action by the nurse?
prepare the client for emergency surgery try to obtain informed consent from a family member wait until the client is conscious, and then obtain the consent ask police to run the tag number so the client can be identified inform the health care provider that consent cannot be obtained at this time
The nurse is charting on his client, who had an open appendectomy the previous day. Which are appropriate nursing documentation entries?
The client appeared anxious when several family members came to visit. The client appeared angry when the health care provider changed her medications. The client tolerated 80% of the lunch tray with no complaints of nausea or stomach cramping. The abdominal dressing is clean, dry, and intact with a 3-cm area of light staining noted…
A nurse is talking to a nursing student about quality improvement and nurse-sensitive indicators. The nurse knows that the nursing student understands quality improvement when she identifies which to be nurse-sensitive indicators?
fall injury rates restraint utilization rates staying within the unit budget upgrading computer charting programs pressure ulcer prevalence and incidence client satisfaction with pain management
The nurse reports to work and finds that a client from the previous day has been assigned to another nurse. The nurse had a great rapport with the client and wonders how he did during the night. She decides to look at the client’s chart to read the progress notes. Which statement is correct regarding the nurse’s actions?
She should go to the client’s room and see how he is doing. She has legal access to the client’s chart since she was involved in his care. The nurse is violating HIPAA regulations and should not be accessing the client’s chart. She should wait and ask the other nurse how the client is doing…
The nurse is caring for a client who is post-op day 1 for a coronary artery bypass graft (CABG). The nurse knows that continuity of care for this client is ensured by doing which of the following?
using standardized handoff reports knowing how to perform a chart check following up on outstanding lab reports and incomplete orders knowing the proper procedures to transfer clients to another floor telling the next shift that they will need to draw blood that was due on the current shift
The charge nurse in the medical unit is preparing a bed assignment for a stable client diagnosed with necrotizing fasciitis. The client has a history of diabetes and hepatitis. There are four beds available. The nurse knows that the best roommate for this client is which of the following?
a client with gout in the large toe a client with fever, vomiting, and diarrhea a client with MRSA a client with severe dementia with a tendency to wander
The ED nurse is working in triage on a summer weekend. The following clients present at the same time. Which client does the nurse anticipate being seen first ?
a 58-year-old man with abdominal pain and nausea an infant with fever, a shrill cry, diarrhea, and nuchal rigidity a 38-year-old jogger who twisted her ankle, has a good pedal pulse, and has no deformity a 46-year-old client who was working outside and has tachypnea, diaphoresis, and fatigue an ambulatory child who fell off a…
The nurse is caring for a client with dyspnea. Which interventions can the nurse delegate to an unlicensed assistive personnel (UAP)?
assessing lung sounds checking a pulse oximetry administering oxygen via nasal cannula encouraging the client to cough and deep breathe showing the client how to use an incentive spirometer