A nurse on a pediatric unit is assisting with the care of four clients. Which of the following clients should the nurse plan to see first? A preschooler who has respiratory syncytial virus and is wheezing When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority client is the preschooler who is wheezing because this client is at risk for a possible airway obstruction. A nurse is observing a newly licensed nurse administer ophthalmic medication to a client. Which of the following actions should the newly licensed nurse take first? Verify the medication with the client's medication administration record (MAR). Evidence-based practice indicates the first action the nurse should take when administering ophthalmic medication is to validate the client's name, the name and dosage of the medication, and the medication prescription, route, and time with the client's MAR. A nurse is participating in discharge planning for a client who has a new tracheostomy. Which of the following equipment should the nurse ensure is available for providing care for a client at home? Portable suction The nurse should ensure that a portable suction device and other suctioning equipment is available in the home to clear respiratory secretions.
A nurse is serving on a performance improvement committee which is reviewing client falls. The data shows that most falls occur between 2000 and 2200. Which of the following recommendations should the committee make? Check on clients hourly. Evidence-based practice has shown that performing hourly rounds to provide assistance with toileting, pain, or client positioning is effective in reducing falls. A nurse is providing care for a group of clients who have signed a general consent for treatment. The nurses should identify that which of the following procedures requires an additional written informed consent? Performing an amniocentesis The nurse should ensure that the client has provided additional written informed consent prior to an invasive procedure, such as an amniocentesis. A nurse is assisting with the care of a client who suddenly becomes unconscious and requires emergency surgery. The client does not have advance directives and the only family member available is the client’s 14- year-old daughter. Which of the following actions should the nurse plan to take? Transport the client to the operating room with implied consent. In an emergency, if it is not possible to obtain informed consent from the client, consent is implied because it is assumed that the client would want the medically necessary surgical treatment. A nurse is completing documentation on the computer at the nurse’s station when an assistive personnel (AP requests to use the computer to enter morning vital signs. Which of the following actions should the nurse take? Ask the AP to find another computer.
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