FREE Registered Nurse: Reduction of Risk Potential Questions and Answers
The 49-year-old pedestrian is taken to the emergency room following an automobile and pedestrian collision. Internal bleeding and a femur fracture are the two diagnosis made by the ED doctor. The nurse tries to get in touch with the next of kin for permission when surgery is recommended. What is the correct procedure for obtaining this client's consent?
Spouse, adult child, parent, and sibling are the proper legal order for requesting consent. According to the doctrine of necessity, permission may be waived in cases of life-saving or urgent surgery.
A 7-year-old girl's bone marrow biopsy will be assisted by a pediatric nurse. The procedure will be done while under conscious sedation. What role does the nurse play primarily?
Every process necessitates that one team member be the only one in charge of keeping track of the patient. The pediatric nurse in this situation will keep an eye on the child's vital signs, reflexes, and reaction to the procedure. The nurse won't leave the patient to provide any relatives an update.
The nurse should initially check the patient's ________ when evaluating a patient in the post-anesthesia care unit (PACU).
Always start by evaluating the postoperative patient's respiratory condition, says the nurse. In the PACU, breathing issues are the second most typical problem. (Vomiting and nausea come first.) A pulmonary embolism, hypoventilation, pneumothorax, and airway blockage are examples of immediate post-anesthesia problems.
When Nurse John arrives for his shift, he observes that Nurse Jane has an alcoholic odor and slurs her speech. What is Nurse John supposed to do?
Never compromise on patient care. Nurse John has to speak with a manager about his findings and worries right away. It is not appropriate for Nurse John to attempt to tackle the matter on his own or help Nurse Jane the entire shift. A report on an incident is inappropriate.
The healthcare provider would most likely anticipate finding during an evaluation of a patient with acute bleeding
In an effort to get the body and brain more oxygen, the heart rate will increase. Pulse rates over 100 bpm are regarded as tachycardia.
An evaluation of a patient who underwent extensive abdominal surgery five days ago is being done by the nurse. When the client coughed, the client claimed to feel a "pop where my operation was." The nurse examines the area and observes that the borders of the wound have split at the point of the incision. What should the nurse start by doing?
Up to 3 percent of abdominal procedures result in postoperative wound dehiscence. A surgical complication known as dehiscence occurs when the borders of the wound open or split along the incision. This may happen five to ten days after surgery. Dehiscence may result by coughing, sneezing, or vomiting, particularly if no splint is present. Another reason is an infection. Clients who are obese, have diabetes or have immune system issues are more likely to develop dehiscence.
The following actions are included in nursing care:
1. Let the HCP know.
2. To ease abdominal tension, place the client in a low-position Fowler's with their knees bent.
3. Apply a clean dressing or towel to the wound.
4. Keep the person completely bedridden and NPO.
5. Adhere to strict asepsis to avoid wound infection.
6. Offer emotional assistance.
A patient arrives to the emergency room with a headache, disorientation, and a blood pressure of 180/130 mmHg. Which other observation supports the diagnosis of a hypertensive emergency?
A abrupt increase in blood pressure that registers at 180/120 mmHg or greater is considered a hypertensive emergency. Intervention is required right away. A hypertensive emergency may result in hemorrhages, exudates, or papilledema due to hypertensive retinopathy. A hypertensive crises can also lead to other complications such a heart attack, stroke, aortic dissection, kidney damage, and pulmonary edema.
A new patient can't take care of their oral hygiene. What guidance should the nurse provide the nurse's assistant out of the following list?
After every meal, a gentle toothbrush should be used. To maintain a clean mouth overall, to stimulate the gums, and to remove plaque, mechanical motion is required. The nurse's job is to evaluate the oral cavity. A foam applicator is insufficient to thoroughly clean the teeth. Mouthwash may cause irritation.
At the local clinic, the healthcare provider is seeing four patients. Which of these people needs to have their risk for iron deficiency anemia identified by the healthcare professional?
For certain women, menstruation may raise their risk of iron deficiency anemia. A typical sign of iron-deficiency anemia is pica, the urge to eat strange things like ice or dirt. There may be a reduction in intrinsic factor and vitamin B12 absorption following gastric bypass surgery. A particular eating regimen is necessary for patients with chronic renal failure. If a vegan diet is carefully planned, iron-deficiency anemia shouldn't occur.
A patient is admitted to the ICU after falling from a ladder and being diagnosed with traumatic brain damage (TBI). He is becoming more restless, the nurse notices, and his right arm is becoming weaker. He also reports feeling sick. What is the BEST thing the nurse can do right away?
The patient's signs and symptoms point to an elevation in intracranial pressure (ICP). The nurse's best immediate course of action is to elevate the bed's head by 30 degrees to reduce the ICP. ICP won't drop with oxygen therapy. The IV dosage increase may be detrimental. Although taking the patient's blood pressure is not something that needs to be done right away, it can be done before telling the doctor about the patient's change in condition.
Which of the following would a healthcare professional anticipate when analyzing the arterial blood gases (ABGs) of a patient with a 20-year history of chronic bronchitis?
Reduced airflow on expiration due to chronic bronchitis traps carbon dioxide (CO2) in the lungs. Respiratory acidosis results from the decreased arterial pH caused by the elevated CO2. By retaining bicarbonate, the kidneys offset the persistent acidity. Due to the pH remaining in the low-normal range, compensatory respiratory acidosis is the result.
For several days, your home health patient has been throwing up. She is currently resting in bed when you arrive. Her eyes are lifeless, and she is pale and listless. She is concerned as well. What is the most likely scenario?
Although severe injury is the most common cause of hypovolemic shock, dehydration from vomiting or diarrhea can also increase the risk. Hypovolemic shock has a more severe impact on older people and can result in heart failure or stroke. Anxiety is another side effect of hypovolemic shock brought on by a drop in oxygen levels in the blood. Fluids should be replenished intravenously.
Monitoring the patient's vital signs is crucial when a healthcare professional is treating a patient with a cardiac dysrhythmia.
It is crucial for the healthcare professional to keep an eye on these laboratory values since anomalies in sodium, potassium, and calcium levels are likely to impact the depolarization and repolarization of cardiac cells. BUN and creatinine levels should always be checked while administering any medication, not just those for anti-dysrhythmia. For patients taking warfarin, the PT and INR are crucial (Coumadin).
A client with amyotrophic lateral sclerosis (ALS) suffers dysphagia, according to a home health nurse. What is the nurse's main worry?
Dysphagia refers to difficulty properly swallowing. The risk of aspiration, which can result in choking or aspiration pneumonia, increases for a patient who develops dysphagia. Dysphasia is the term for speaking difficulties. Drooling is common in ALS patients; while it is uncomfortable and embarrassing for the patient, it is not a serious problem right away. Poor dental hygiene may lead to mouth infections, however this is not a serious issue right away.
On your floor is a 50-year-old patient who is blind and deaf. What is your primary duty to this patient as the charge nurse?
Anyone with a handicap is protected against discrimination under the American Disabilities Act (ADA). In order to reduce the risk of injury to patients, visitors, and employees, hospitals and other healthcare facilities must provide access and accommodations.
After discovering his two-year-old son next to an empty aspirin bottle, the father brings him to the emergency room. While unconscious, the youngster is breathing. What will the nurse do right away?
The initial step in an overdose situation is to emesis or lavage the toxin out of the body. Lavage is the only method available because the boy is unconscious. Although a salicylate overdose from aspirin can cause respiratory collapse, the child is breathing. Authorities from Family Services are not involved in efforts to revive the patient right away, and education at this time is ineffective.