- A nurse enters a clients room and finds. The nurse makes the client comfortable on the bed and completes an examination. " ANS: C (stay at safe distance and remain calm), 3. 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. " 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. This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room and finds him unresponsive. "Incident report completed" b. 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. check for a carotid pulse c. When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. 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. The nurse enters a clients room and finds that the wastebasket is on fire. 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. Clients are panicking and the room is filling with smoke . " b. 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. 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. An older adult who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7. attach defibrillator pads to the client b. IV lidocaine B. 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. 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. The client is lying in a supine position and is weak, pale, and diaphoretic. 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. 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. A nurse enters a client's room and finds the client on the floor having a seizure. 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. A nurse is caring for a client who has borderline personality disorder. Which action by the nurse would be most appropriate for the nurse to take? 1. 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. Check the client for injuries. 4\. Which is the next nursing action? 1. A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. " d. "Are you almost ready to be discharged?" c. Activate the fire alarm 4. Call for help. 2. "Look how cute she is. Document as required by the facility 2. "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. Notify the client's provider C. 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. The client states she slipped while getting out of bed. Report the client's fall to the facility administer 2. Immediate defibrillation D. 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. " Which of the following responses should the nurse make?, A nurse enters a client's room and finds the client crying. 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. Which statement conveys empathy by the nurse?, A nurse is caring for a client admitted to the hospital for dehydration. A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. , 12. Indicate the emergency actions the nurse must take. What is the next nursing action? 1\. 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. Insert a tongue blade in the client's mouth. after notifying the rapid response team, which of the following actions should the nurse take first? a. Position the head tilted forward. Confine the fire by closing the room door The nurse enters a client's room and finds that the wastebasket is on fire. Indicate the emergency actions the nurse must take . 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. The client reports falling while trying to go to the restroom. Ask the client to stop 2. Use all the steps . Which of Swanson's five categories of caring behaviors is the nurse demonstrating? and more. 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. 3\. The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart. The client, grimacing, says "It's fine. Place a pillow under the client's head C. The nurse enters the client's room and finds the client sitting in the dark crying. Chemical cardioversion C. Move the client back into bed D. 3. 32 b The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97. The client looks at the nurse and says, "Back off. The nurse makes the client comfortable on the bed and completes an assessment. î C) turn and walk away from the room without saying anything. 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. Extinguish the fire. Activate the fire alarm. 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 completely unresponsive. The physician 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. " Which of the following actions by the nurse is appropriate? 1. 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. Ignore the client activity 3. B. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. 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. 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. Gently restrain the client's extremities D. D. , 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. ), 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. 2\. What statement should the nurse make? a. Your behavior is unacceptable. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket. Shout for the code The nurse enters the client's room and finds the client crying. Inadequate vitamin D intake 2. Start chest compressions 4. Open the airway 2. Notify the client's physician and family 3. 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. Answer and Explanation. 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. Inadequate protein intake 3. Which action should the nurse perform first? 1. ( Move the steps into the box on the right , placing them in the selected order of performance . 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. Place the client on his side. Which of the following statements should the nurse document about this incident? a. Move the client to the couch. 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. 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. 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. Which should the nurse do to safely manage the Tell me what is making you feel so tense. Extinguish the fire 3. " Which of the following statements should the nurse make? a. 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. Hold the client's arms and legs from moving. 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). After providing first aid, which of the following actions should the nurse perform? a. A. 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. The nurse enters the client's room and finds the client cutting into his flesh with a paper clip. What is the purpose of an incident report? A. Which of the following interventions should the nurse take? A. The Correct Answer is 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 . Breathing is shallow and a pulse is present. " What should the nurse do next?, The nurse delivers a 10 mg tablet rather than the 5 mg ordered. 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. Leave me alone. Begin chest compressions d. The nurse quickly assesses the client and discovers that the client is not breathing and there is no pulse. Ask an AP to sit with the client. 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. Insert a padded tongue blade into the client's mouth B. "I will leave you alone for a d=few minutes while you try to control yourself. Complete an incident report B. Low calcium level, A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Place a pillow under the head. b) Request another nurse to complete the occurrence report. To which of the following concepts is the provider referring?, A nurse manager is planning an in-service about culturally competent care. Document the activity in the client's chart. Which of the following actions should the nurse take first? Notify the charge nurse and the client's provider. 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. "You should always hold your baby for feedings instead of propping the bottles. 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. Which of the following clients should the nurse recommend for discharge? a. What is the priority nursing action? a. The nurse enters a client's room and finds that the wastebasket is on fire. The nurse continues to assess the client, but the client begins to vomit large amounts of bright red blood. 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. 4. 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. Tell the client that he will be put in restraints if he attempts to get out of bed again. The nurse would document this client's level of arousal as . What is the nursing action? 1. 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. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Extinguish the fire. Place the following activities in the correct order. Which recommendation would be most appropriate to include in the client's plan of care? Select all that apply. What is the best response by the nurse? The nurse enters a client's room and finds the client masturbating. While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and bathroom. Assess the client's carotid pulse and assess if the client is breathing B. The nurse immediately assists the client out of the room. The Correct Answer is B. 1. Use the fire extinguisher. The client says to "set it down, I'll take it after I finish eating. 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. A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. The client states, "I fell because no one would help me to the bathroom, but I think I can get up okay. " "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. The family requested DNR status from the provider, but the provider hasn't written the prescription yet, what does the nurse do? a. , While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. A nurse enters the room of a client and finds the client lying on the floor who is on contact precautions. The nurse helps the client to get up, makes him comfortable, and then informs the health care provider. What is the purpose of an incident report? A) To provide a method for deciding the nurse's fault in the incident. Request help to assist the client A nurse enters a client's room and finds the client pulseless. Loosen tight shirt or jacket. Use all the steps. 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. In which order of priority from first to last should the nurse take the following actions? 1. 2°F (36. After stabilizing the client, the nurse informs the physician. What is the purpose of an incident report? The nurse enters the client's room and finds the client pulseless and unresponsive. The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. , The nurse enters a client's room and finds the client slumped over in bed. Resuscitation is initiated and then continued by the rapid response team. 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. , A nurse is caring for a client who is newly diagnosed with terminal cancer. Which actions should the nurse take first?, The nurse enters an adult patient's room and finds him unresponsive. The nurse sits beside the bed in silence. "Is she almost done feeding?" A nurse enters the clients room and finds the client pulseless. "I demand that you calm down now. Clients are panicking and the room is filling with smoke. Which of the following actions should the nurse take first? A. The nurse then informs the physician and the nursing supervisor about this incident and also completes an incident report. 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. 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. The health care provider advises the nurse to prepare an incident report. 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. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36. 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. 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. Which of the following actions should the nurse take? A. 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. Complete an incident report. Place the client back in bed. Call for help 2. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. (Move the steps into the box on the right, placing them in the order of performance. Which nursing interventions should the nurse implement? Select all that apply 1. 2° C (97. 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. 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 LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. 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. 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. What would be the treatment of choice for this client? A. Confine the fire by closing the room door. Give the client oxygen 3. C. After determining that the client is unresponsive, the nurse should perform which actions? Place the actions the nurse should take in the appropriate order. 5. For which of the following adverse The nurse enters a client's room and finds that the wastebasket is on fire. Inadequate massaging of the affected area 4. 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. gys sup oybp eyqq xoiel excdxd mwiyo hewc qnur gashn