Which of the following interventions takes priority when a nurse is ending a shift?
•Documentation is very important. It provides a legal record of the interventions performed by the nurse. If it was not charted, it (legally) was not done.
•The other three options do not take priority over documentation.
A postoperative patient is in the post-anesthesia care unit (PACU) after undergoing an appendectomy. The nurse assessed the patient's vital signs with a temperature of 94.5
A patient in a long-term care facility is irritable and labile and has been being rude to staff throughout the shift, using obscenities and foul language. A nurse administers 10 mg haloperidol (Haldol) IM for severe agitation. You know this is an example of which of the following?
When administering an IM injection to an adult, the nurse ensures proper insertion depth by choosing a needle length of:
A terminally ill patient has identified her husband as her durable power of attorney. The husband then demands that a new physician take over his wife's care. How should the nurse react?
The physician is obtaining surgical consent from a blind patient. Which of the following should the nurse do to ensure the informed consent is understood by the patient?
A nurse is preparing an IV medication from a vial. After the nurse removes the cap from the unused vial, the nurse should:
A nurse is called to respond to a bioterrorism disaster in the city. Which of the following is true regarding bioterrorism events?
After giving a patient two 500mg acetaminophen tablets for a headache, the nurse realizes that the order was for two 325mg acetaminophen tablets. After notifying the physician and the charge nurse of the error, where should the nurse document this medication error?
A nursing student administers an IV medication but forgets to prime the syringe. The patient then becomes confused and pale. Suspecting an air embolus, what is the appropriate response?
A nurse on the medical surgical floor is caring for a patient admitted to the hospital after the patient was assaulted by their spouse. The nurse is paged to the nurses' station for a phone call. The caller is requesting information on the status of the patient that was admitted after being assaulted. The nurse knows it is appropriate to discuss which of the following with the caller?
A 59-year-old female is complaining that she lacks enough sleep ever since she was admitted to the hospital. The nurse notes that the patient is restless, frequently yawns, and has teary eyes. In order to to promote rest and sleep, the nurse will:
A nurse on the medical surgical floor is caring for a patient who is confused and combative after abdominal surgery. The patient has pulled out the nasogastric (NG) tube required for gastric rest. The nurse called the doctor to discuss these issues. The doctors ordered 2-point restraints, so the nurse creates a telephone order read back (TORB). The nurse knows that the restraint order will require which of the following?
A patient with advanced lung cancer is on the transplant list. While discussing the patient's situation, the physician states that the patient will probably continue smoking even if they receive a transplant. How should the nurse respond to advocate for the patient?
A nurse on the medical surgical floor enters a patient's room and finds the patient unresponsive to verbal stimuli. What should the nurse do next?
A nurse is caring for a 7-year-old with appendicitis and multiple bruises. The nurse suspects the child is being abused. What should the nurse do?
A nurse on a busy medical-surgical floor has a certified nursing assistant assigned to her patients. The nurse has delegated to the CNA to obtain patient vital signs. The CNA reports to the nurse a blood pressure reading of 82/40 on a patient with atrial fibrillation. The nurse should do which of the following first?
A nurse on the cardiovascular step-down unit is caring for a patient who is postoperative day 2 after arterial bypass surgery. The patient has a PCA with hydromorphone infusion and has hydrocodone 10 mg po Q4 hours ordered for breakthrough pain. During morning assessment, the patient complains of pain rated 10 on a scale of 0 to 10. The nurse offers the patient the hydrocodone for breakthrough pain. The patient states, "I asked for pain medication from the other nurse and was told no because I have a PCA." On further questioning, the patient stated that the other nurse threatened to disconnect the PCA if the patient continued to complain. The nurse knows the next appropriate action is which of the following?