Study guides, Class notes & Summaries

When do *advanced directives* go into effect? - Answer when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* - *coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as signed; directives can always be changed later by person) SBAR Communication Framekwork Components - Answer 1. *S* = Situation - what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background - *pertinent information, relevant history, vital signs* 3. *A* = Assessment...

A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse initiate first? Click on the exhibit button for additional information. - Answer Normal saline 2 L via rapid IV bolus. A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? - Answer Refer employee to the employee health...

The charge nurse overhears an AP yelling loudly to a patient who is hard of hearing, while transferring them from the bed to a chair. Upon entering the room, which response by the charge nurse is most appropriate? a. "Please speak more quietly so you don't disturb the other patients." b. "Let me help you with your transfer technique." c. "When you are finished, be sure to apologize for shouting." d. "When your patient is safe and comfortable, meet me at the desk." - Answer d. The ...

BPH assessment? - Answer >50 voiding difficulty/urgency incomplete emptying straining to void nocturia urine retention Should never have burning with uriantion! this indicates a UTI Sexual intercourse does not have anything to do with this PAtient with altered level of consciousness positioning? - Answer side lying position septic shock symptoms - Answer Tachycardia, fever,hypotension (SYSTOLIC lower then 90), pallor, fatigued, cold, reduced urine output, SOB,...

Diagnosis - genetic disorder with absent/malfunctioning LDL receptors leading to elevations in both total cholesterol and LDL cholesterol leading to atheromas and xanthomas - Answer Familial hypercholesterolemia Tumor - cells produce non-membrane-bound cytoplasmic lipid - Answer Liposarcoma Term - unequal size of pupils - Answer Anisorcoria Compressed in a Pancoast tumor causing Horner syndrome - Answer Sympathetic trunk (superior cervical ganglia) Mechanism - lithium induced...

AD - Answer -A progressive neurodegenerative disease that causes dementia (reduced cognitive function) -There is a reduction in cognition -conversations become progressively more difficult and word-finding difficulties occur -the best way for the nurse to obtain information is to use simple sentences in a calm environment Hearing loss patients - Answer -touching the client before speaking to them -Speak loudly -Stand close to the person Clients with insomnia, you are teaching sle...

The nurse is caring for a client returning from the cardiac cauterization laboratory following stent placement through the femoral artery. The client immediately vomits when transferring from the stretcher to the bed. What action should the nurse perform FIRST? 1. Administer IV ondansetron PRN 2. Change the client's gown and linens 3. Check the dressing over the groin insertion site 4. Request a prescription for fluid replacement - Answer 3. Check the dressing over the groin insertion s...

A nurse coworker is called into work from home to help care for an influx of clients being admitted after a bus accident. While assisting the coworker prepare for incoming clients, the nurse becomes concerned that the coworker may be under the influence of an impairing substance. Which action by the nurse is best? 1. Ask another coworker to observe the individual to confirm the suspicion 2. Confront the coworker about the concern and offer emotional support 3. Speak with the nursing superv...

B/P Medication side effects? - Answer - fatigue - erectile dysfunction - dizziness Angina pectoris risk factors? - Answer - Smoking - Extreme temperatures - Physical exertion (including sex) - Intense emotion - Coronary artery narrowing - Stimulants (cocaine, amphetamines) Define angina pectoris - Answer Chest pain due to myocardial ischemia (decreased blood flow to heart). Purpose of an ICD (implantable cardioverter defibrillator)? - Answer - sense and defibrillate life-...

The nurse is caring for a client who is 2 days postoperative craniotomy with bone flap removal. The nurse notes clear wound drainage saturating the dressing over the incision. Which action by the nurse is most appropriate at this time? 1. Cleanse the incision site with saline and apply a new, sterile dressing 2. Mark the edges of the drainage on the dressing and continue to monitor 3. Notify the health care provider of the color and amount of drainage 4. Turn the client onto the nonopera...