The medical-surgical floor receives a patient from the postanesthesia care unit (PACU). Ten minutes ago, the final assessment in PACU indicated that the client had a patent airway and stable vital signs. The client's pain level was "2." What should the nurse do next? • Check the dressings for signs of bleeding • Empty any surgical drains • Reassess the client's pain level Assess the client bladder
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This includes checking the patient's heart rate, blood pressure, respiratory rate, and oxygen saturation. Show more…
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Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: • Physical assessment begins. • Review of the assessment is conducted with other team members. Plan is developed for nursing care • List of priorities is determined.
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After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A 60-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. A 70-year-old with pneumonia who needs to be started on intravenous (IV) antibiotics. A 50-year-old with asthma who complains of shortness of breath after using a bronchodilator. A 55-year-old with COPD and a pulse oximetry reading from the previous shift of 90%
33. A nurse was documenting information in a client electronic medical record is asked to assist with an emergency. Which of the following actions should the nurse take? Ask another nurse to monitor the computer, move the computer to secure place, print out the current notes to finish later, turn the computer monitor off 34.A nurse is preparing to obtain informed consent from a client who speaks with a different language than the nurse and is scheduled for surgery. Which of the following actions should the nurse take? address all questions to the interpreter, use medical terminology when explaining the procedure, have a client nod to indicate understanding, recommend an interpreter who is the same gender as the client 35.The nurse is providing teaching to the family of a client who is at the end Stage of life. Which of the following client manifestations to the nurse instruct the family to expect? Altered breathing patterns, increased periods of wakefulness, warm and dry extremities, increased salivation 36.A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identifier? Room number, age, bed number, photograph 37.A nurse is preparing to collect a sputum specimen from a client. Which of the following should the nurse take? Obtain the sputum specimen after the client uses mouthwash, collect the sputum specimen in the morning, you sterile gloves to obtain the sputum specimen, placed the sputum specimen in a clean conTainer 38.A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as part of a full liquid diet? Scrambled eggs, oatmeal, applesauce, plain yogurt
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