Which initial action would the nurse take when a patients symptoms have changed from those that were recorded earlier quizlet?

When assessing a patient with a terminal illness, the nurse notes the patient's monosyllabic replies and limited eye contact. Which direct care intervention does the nurse perform?

Direct care interventions are treatments nurses provide through interactions with patients or a group of patients. For example, a patient receives direct intervention in the form of medication administration, insertion of a urinary catheter, discharge instructions, or counseling during a time of grief. The other three interventions are indirect care interventions, which are described as treatments performed away from a patient but on behalf of the patient or group of patients (e.g., managing a patient's environment [safety and infection control]), documentation, and interprofessional collaboration. Ensuring privacy is managing the patient's environment. Requesting an analgesic is a treatment on behalf of the patient. Consulting a palliative care team is an example of interprofessional collaboration. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

Which factor would the nurse consider when making discharge plans for activities of daily living (ADLs)? Select all that apply. One, some, or all responses may be correct.

The nurse would consider the following: a paralyzed patient will need permanent assistance for ADLs, patients should be encouraged to participate in ADLs, and family members can be allowed to assist the patient, as needed. A paralyzed patient has a permanent need for full assistance with ADLs. Patients like to be independent and should be allowed to participate as much as possible. If the patient wishes to be assisted by his or her family members, it can be allowed. A patient with a fractured arm will need assistance writing checks, but the question asked for ADLs, not for assistance with instrumental activities of daily living (IADLs). The statement that only a professional nurse can provide ADLs is false; many others can provide ADLs. Test-Taking Tip: The presence of absolute words and phrases can also help you determine the correct answer. If answer choices contain an absolute (e.g., none, never, only, must, cannot), be very cautious. Remember that there are not many things in the world that are absolute, and in an area as complex as nursing, an absolute may be a reason to eliminate it from consideration as the best choice. This is only a guideline and should not be taken to be true 100% of the time; however, it can help you reduce the number of choices. For this question, one of the choices can be eliminated because of the word only.

Which intervention would be appropriate for a postoperative patient who is on bed rest and at risk of skin injuries after surgery? Select all that apply. One, some, or all responses may be correct.

The nurse would reposition the patient frequently, administer analgesics before turning, and use pressure relief devices, if necessary. The patient is at a high risk of developing pressure injuries. Therefore the nurse would implement measures to prevent complications. Patient education should happen before surgery, when the patient is more receptive, not after surgery. After surgery, the patient may have pain and may not be able to learn because of the pain. This patient is on bed rest, so the patient cannot ambulate until the prescription is changed.
STUDY TIP: Prepare for examinations when and where you are most alert and able to concentrate. If you are most alert at night, study at night. If you are most alert at 2:00 AM, study in the early morning hours. Study where you can focus your attention and avoid distractions. This may be in the library or in a quiet corner of your home. Do what is working for you. If you are distracted or falling asleep, you may want to change when and where you are studying.

Which intervention would the nurse perform for a patient who has developed a hypersensitivity reaction to penicillin and has developed hives? Select all that apply. One, some, or all responses may be correct.

The nurse would perform the following interventions: record the reaction, inform the health care provider, administer diphenhydramine, and reassure the patient. When a patient develops a hypersensitivity reaction to a drug, the nurse would record the reaction. This helps describe the reaction and inform the other health care professionals. The health care provider should be notified of the reaction so the nurse can get further prescriptions or change the treatment. Diphenhydramine, an antihistamine and antipruritic medication, should be administered to relieve the allergic response. The patient may be worried, so the nurse should reassure the patient. Because the patient is allergic to the drug, it should be stopped. A reduced dose may also evoke the same response.

Which action comes first when developing a nursing process?

Which action would the nurse take during the implementation phase?

Which activity should the nurse perform before implementing interventions for a patient per the nursing plan of care?

Which priority action would the nurse take before administering a new drug?