A nurse enters a clients room and finds. Which of the following actions should the nurse take first? A. 2° C (97. When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. 3\. 2\. A nurse enters the room of a client and finds the client lying on the floor who is on contact precautions. " ANS: C (stay at safe distance and remain calm), 3. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?, A nursing is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. An older adult who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7. Indicate the emergency actions the nurse must take. Complete an incident report B. The nurse enters a clients room and finds that the wastebasket is on fire. The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Request help to assist the client A nurse enters a client's room and finds the client pulseless. The nurse helps the client to get up, makes him comfortable, and then informs the health care provider. Extinguish the fire 3. The nurse immediately assists the client out of the room. Document as required by the facility 2. The Correct Answer is B. " b. Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room and finds him unresponsive. 2°F (36. Assess the client's current condition and vital Study with Quizlet and memorize flashcards containing terms like The family member of a patient who has been admitted to the ICE with multiple traumatic injuries have just arrived in the ICU waiting room. The nurse enters the client's room and finds the client sitting in the dark crying. Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room and finds that the client is lying on the floor. 1. Which of the following actions should the nurse take first? Notify the charge nurse and the client's provider. What is the purpose of an incident report? The nurse enters the client's room and finds the client pulseless and unresponsive. The health care provider advises the nurse to prepare an incident report. After determining that the client is not breathing and does not have a pulse A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. The nurse then informs the physician and the nursing supervisor about this incident and also completes an incident report. Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room and sees smoke coming from the bathroom, Which of the following actions should the nurse take first?, A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. 32 b The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97. Which statement conveys empathy by the Study with Quizlet and memorize flashcards containing terms like The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Document the activity in the client's chart. Ignore the client activity 3. Clients are panicking and the room is filling with smoke. Which of the following actions should the nurse take first?, An RN on a medical-surgical unit is making assignments at the beginning of the shift. Which is the next nursing action? A nurse enters a client's room and sees the client lying on the floor next to the bed. Tell the client that he will be put in restraints if he attempts to get out of bed again. Place the client back in bed. Start chest compressions 4. Which of the following interventions should the nurse take? A. This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. Low calcium level, A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. deliver two breaths, a nurse enters an adult client's room and finds A nurse enters a client's room and finds her on the floor. What statement should the nurse make? "Are you almost ready to be discharged?" "Is she almost done feeding?" "You should always hold your baby for feedings instead of propping the bottles. Use all the steps . What would be the treatment of choice for this client? A. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket. Which of the following actions should the nurse take? A. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. What is the nursing action? 1. Position the head tilted forward. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36. Extinguish the fire. To which of the following concepts is the provider referring?, A nurse manager is planning an in-service about culturally competent care. The Correct Answer is C. A nurse enters a client's room and finds the client on the floor having a seizure. Gently restrain the client's extremities D. 4\. Call for help. Which recommendation would be most appropriate to include in the client's plan of care? Select all that apply. Which of the following clients should the nurse recommend for discharge? a. Which physical findings should the nurse Study with Quizlet and memorize flashcards containing terms like A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. Which of the following food items brought by the family should the nurse prohibit from being given to the client?, A nurse enters a client's room and finds the client pulseless. The client states she slipped while getting out of bed. Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room and observes that the client is agitated and pacing rapidly. Place the client on his side. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Breathing is shallow and a pulse is present. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Answer and Explanation. Place the following activities in the correct order. A. Your behavior is unacceptable. " d. Which is the correct intervention by the nurse? Sit down quietly next to the bed and allow the client to cry. A nurse enters a client's room and finds the client pulseless, the nurse knows the client's family has requested DNR status form provider but the provider has not written the order, what is the first thing to do? 5. The family requested DNR status from the provider, but the provider hasn't written the prescription yet, what does the nurse do? a. Ask an AP to sit with the client. The nurse makes the client comfortable on the bed and completes an assessment. "Is she almost done feeding?" A nurse enters the clients room and finds the client pulseless. Encourage the client to discuss feelings about his self-injurious behavior during group Study with Quizlet and memorize flashcards containing terms like The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). The client says to "set it down, I'll take it after I finish eating. After providing first aid, which of the following actions should the nurse take first?, A nurse is assessing a client who is experiencing moderate-level anxiety Study with Quizlet and memorize flashcards containing terms like A nurse is changing a dressing and providing wound care. Inadequate massaging of the affected area 4. Which of the following actions should the nurse take/ Choose matching definition Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who sates the health care provider recommends treatment to provide comfort because a cure is not possible. "Look how cute she is. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. The client states, "I fell because no one would help me to the bathroom, but I think I can get up okay. Which question should the nurse use to maximize communication with this patient?, A nurse enters a client's room and asks about his level of pain. Confine the fire by closing the room door Study with Quizlet and memorize flashcards containing terms like The nurse wants to gain information about a clients situation. After determining that the client is unresponsive, the nurse should perform which actions? Place the actions the nurse should take in the appropriate order. Activate the fire alarm 4. Which of the following statements should the nurse document about this incident? a. "You should always hold your baby for feedings instead of propping the bottles. What is the next nursing action? 1\. What is the nurse's best action?, A client severely injured in The client is restless, and the pulse rate is increased. Activate the fire alarm. Ask the client to stop 2. The nurse makes the client comfortable on the bed and completes an examination. Resuscitation is initiated and then continued by the rapid response team. Confine the fire by closing the room door. Inadequate vitamin D intake 2. Which is the next nursing action? 1. Check the client for injuries. "Are you almost ready to be discharged?" c. The client is lying in a supine position and is weak, pale, and diaphoretic. Indicate the emergency actions the nurse must take . Use the fire extinguisher. Assess the client's carotid pulse and assess if the client is breathing B. Give the client oxygen 3. The nurse enters the client's room and finds the client cutting into his flesh with a paper clip. Extinguish the fire. The client reports falling while trying to go to the restroom. Based on this data, the nurse determines that which action is the priority?, A client with heart failure who is taking furosemide and digoxin calls the nurse and complains of anorexia and nausea. Leave me alone. Study with Quizlet and memorize flashcards containing terms like A nurse enters the client's room and finds the client lying on the floor with ongoing seizures. Which nursing interventions should the nurse implement? Select all that apply 1. What is the priority nursing action? a. Inadequate protein intake 3. Use all the steps. Call for help. B. What is the purpose of an incident report? A) To provide a method for deciding the nurse's fault in the incident. Which is the nurse's priority concern?, Which positions is used to help reduce intracranial pressure (ICP)?, To meet the sensory needs of a client with viral meningitis, the nurse should: and more. Chemical cardioversion C. The client, grimacing, says "It's fine. ( Move the steps into the box on the right , placing them in the selected order of performance . For which of the following adverse The nurse enters a client's room and finds that the wastebasket is on fire. Activate the fire alarm. Which of the following actions should the nurse take? Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is newly diagnosed with terminal cancer. 3. The nurse sits beside the bed in silence. (Move the steps into the box on the right, placing them in the order of performance. The nurse would document this client's level of arousal as . The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. " Which of the following statements should the nurse make? a. b) Request another nurse to complete the occurrence report. î C) turn and walk away from the room without saying anything. after notifying the rapid response team, which of the following actions should the nurse take first? a. Shout for the code The nurse enters the client's room and finds the client crying. What type of question should the nurse first ask the client in this interaction? A yes or no question A directing question An open-ended question A reflective question, A dialysis nurse is educating a client on The client tells the nurse, "I don't want to take that medication because it makes me sleepy. Call for help 2. The nurse enters a client's room to administer oral medications and finds unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The nurse quickly assesses the client and discovers that the client is not breathing and there is no pulse. , 12. Quietly leave the room Study with Quizlet and memorize flashcards containing terms like The nurse enters her client's room and finds the infant on a pillow with a bottle propped up while the mother is dressing. Begin chest compressions d. Insert a wash cloth between the teeth Study with Quizlet and memorize flashcards containing terms like A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Which action should the nurse perform first? 1. Open the airway 2. Which statement conveys empathy by the nurse?, A nurse is caring for a client admitted to the hospital for dehydration. to provide The nurse enters the client's room and finds the client anxiously pacing the floor. The nurse quickly assists the client out of the room. D. Electric cardioversion Study with Quizlet and memorize flashcards containing terms like Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following tasks should the nurse delegate to the PN?, A PN A nurse enters the room of an older adult client and finds him attempting to crawl over the side rail. Place a pillow under the head. 2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart. Move the client back into bed D. , While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. Which actions by the nurse indicates correct Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room and finds the client lying on the ground. What statement should the nurse make? a. "Incident report completed" b. 2° F) orally, pulse 52 beats per A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. " Which of the following actions by the nurse is appropriate? 1. Which action is correct? Study with Quizlet and memorize flashcards containing terms like The nurse on the day shift walks into a client's room and finds the client unresponsive. ), A nurse is Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room and finds the client slumped down in the chair. After stabilizing the client, the nurse informs the physician. Hold the client's arms and legs from moving. Which action by the nurse would be most appropriate for the nurse to take? 1. The nurse continues to assess the client, but the client begins to vomit large amounts of bright red blood. Notify the client's provider C. Study with Quizlet and memorize flashcards containing terms like A nurse in a long - term care facility enters the day room and finds the window curtains on fire . 2. What would be the nurse's most appropriate initial response?, Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen?, After a client Study with Quizlet and memorize flashcards containing terms like 1. Report the client's fall to the facility administer 2. The nurse enters a client's room and finds that the wastebasket is on fire. "I will leave you alone for a d=few minutes while you try to control yourself. "I will close the door to provide privacy Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Immediate defibrillation D. Keep the client in a supine A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. , A nurse enters a client's room and finds the client completely unresponsive. check for a carotid pulse c. In which order of priority from first to last should the nurse take the actions? All options must Study with Quizlet and memorize flashcards containing terms like A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. Which is the nurse's priority concern? Airway clearance Risk of injury Deficient fluid volume Risk for impaired skin integrity, A client with meningitis has a history of seizures. IV lidocaine B. Loosen tight shirt or jacket. The client begins shouting at the nurse, ìGet out of my room!î The best intervention by the nurse would be to A) approach the client and ask, ìWhat's wrong?î B) call for help and say, ìCalm down. Insert a tongue blade in the client's mouth. What is the best response by the nurse? The nurse enters a client's room and finds the client masturbating. C. Which of the following cultural competences should the The nurse enters the client's room and finds the client having a seizure on the floor. After the nurse has ensured the client's safety, which of the following actions should the nurse take? a) Document the completion of an occurrence report in the client's medical record. Which of Swanson's five categories of caring behaviors is the nurse demonstrating? and more. " Which of the following responses should the nurse make?, A nurse enters a client's room and finds the client crying. which of the following interventions should the nurse include in the plan, A nurse is Study with Quizlet and memorize flashcards containing terms like In order to safely apply the six rights of giving medication, what must the nurse confirm?, The nurse enters the client's room to administer a medication. Which The nurse enters a client's room and finds that the telephone is lying in the client's lap, tissues are wadded up on the bed, and the client's eyes are red and watery. Obtain the clients vital signs Ask the client, "Do you learn best by observing, valuing, or doing?" Determine client learning needs based on age and ability to hear effectively. The nurse A nurse enters the room of an older adult client and finds him attempting to crawl over the side rail of his bed. The physician advises the nurse to prepare an incident report. Remove the client from The nurse enters her client's room and finds the infant on a pillow with a bottle propped up while the mother is dressing. While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and bathroom. A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. Clients are panicking and the room is filling with smoke . The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the provider has not written the prescription yet. , A a nurse enters a clients room and finds that the client has fallen on her way to the bathroom what is a prudent nursing intervention for this client -history of a fall -having a fractured leg - administration of oxycodon (drowsy pain medication) Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room and observes that the client is hunched over and appears to be breathing rapidly. Study with Quizlet and memorize flashcards containing terms like The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. , A nurse is caring for a client who is newly diagnosed with terminal cancer. " What should the nurse do next?, The nurse delivers a 10 mg tablet rather than the 5 mg ordered. Ventilate with a mouth-to-mask Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has borderline personality disorder. What is the purpose of an incident report? A. " "Look how cute she Aug 3, 2024 ยท Study with Quizlet and memorize flashcards containing terms like A nurse is providing care to a client with an impairment in cognitive function. Move the client to the couch. A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. "I demand that you calm down now. Place a pillow under the client's head C. Insert a padded tongue blade into the client's mouth B. 4. 5. In which order of priority from first to last should the nurse take the following actions? 1. After providing first aid, which of the following actions should the nurse perform? a. A nurse is caring for a client who has borderline personality disorder. attach defibrillator pads to the client b. Complete an incident report. Which should the nurse do to safely manage the Tell me what is making you feel so tense. Which actions should the nurse take first?, The nurse enters an adult patient's room and finds him unresponsive. Confine the fire by closing the room door The nurse enters a client's room and finds that the wastebasket is on fire. , The nurse enters a client's room and finds the client slumped over in bed. The nurse knows the client's family has requested do-not A nurse enters a client's room and finds the client on the floor. Notify the client's physician and family 3. The client looks at the nurse and says, "Back off. " Which communication factor is the client struggling with?, A nurse is working A nurse enters a client's room and finds the client lying on the floor at the bedside. czvjuedoxytygqtmbhkousdwchexexfjrsfwafoursf
