A nurse enters a clients room and finds. I don't take an orange pill". Document the activity in the client's chart. , While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. Insert A nurse enters a client's room and finds the client on the floor having a seizure. Position the head tilted forward. Close the door to the client's room b. Which nursing interventions should the nurse implement? 1. What would be the treatment of choice for this client? a. What is the next nursing action? 1\. The nurse enters a client's room and finds the client slumped over in a chair. The physician An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. î C) turn and walk away from the room without saying anything. This injury primarily falls within the scope of what government agency?, A confused client entered the dirty supply room on the unit and was found rummaging through trash that contained blood and body fluids. Which is the nurse's priority concern?, Which positions is used to help reduce intracranial pressure (ICP)?, To meet the sensory needs of a client with viral meningitis, the nurse should: 1. Which of Swansons five categories of caring behaviors is the nurse demonstrating? Knowing Being With Doing for maintaining belief and more. Which of the following tasks should the nurse delegate to the PN?, A PN A nurse enters a client's room to administer medication and finds the client lying in bed disoriented with labored and fast respirations. Which of the following clients should the nurse recommend for discharge? a. What type of fire extinguisher is most appropriate for the nurse to use in this situation? 1. " Which of the following actions by the nurse is appropriate? 1. The client starts crying and informs the UAP of the Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room and finds the client slumped down in the chair. The nurse delivers compressions by pushing Study with Quizlet and memorize flashcards containing terms like A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. Place the client on a firm surface. After determining that the client is not breathing and does not have a pulse, Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room and finds that the client is lying on the floor. When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazard(s)? Select all that apply 1. Fill out an incident report for risk management about the Study with Quizlet and memorize flashcards containing terms like A nurse enters the room of a client who is on contact precautions and finds the client lying on the floor. Which of the following actions should the nurse take/ The nurse enters a clients room and finds that the telephone is lying in the clients lap, tissues are wadded up on the bed, and the clients eyes are red and watery. R Using endotracheal suctioning to remove secretions the client is unable to clear is important. Confine the fire by closing the room door The nurse enters the client's room and finds the client pulseless and unresponsive. A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. A nurse enters a client's room and finds him unresponsive. Quietly leave the room Study with Quizlet and memorize flashcards containing terms like A nurse is giving a presentation on malpractice. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room to find the client on the floor having a seizure. A nurse is caring for a client admitted to the hospital for dehydration. After notifying the rapid response team, which of the following actions should the nurse take first? Attach defibrillator pads to the client. Prepare the client for endotracheal suctioning. Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room and finds the client lying on the ground. The client says to "set it down, I'll take it after I finish eating. A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. Place a pillow under the client's head. The nurse quickly assists the client out of the room. The nurse enters a client's room and finds that the wastebasket is on fire. Encourage the client to discuss feelings about his self-injurious behavior during group A nurse enters a client's room and finds the client completely unresponsive. What actions should the nurse take? Rank in chronological order. Put a heavy blanket over the lamp 2. Solutions Available. A client tells the nursing assistant "I am so worried about the results of the biopsy they took today. Call for help. C. Place a pillow under the head. Instruct The nurse enters a client's room and finds the client masturbating. Which of the following actions should the nurse take first?, An RN on a medical-surgical unit is making assignments at the beginning of the shift. Question: nurse enters a client's room and finds the client lying on the floor in a puddle of water . The nurse asks the client to rate the current level of pain. A nurse is collecting data from a client who has a wrist restraint in place. Notify the client's provider C. Breathing is shallow and a pulse is present. The nurse enters the client's room to perform a postpartum assessment 1 hour after vaginal birth. Electric cardioversion d. 2°F (36. Use all the options. which of the following interventions should the The nurse is demonstrating which of the following ethical principles?, A nurse is administering an oral medication twin older adult client. Territoriality 2. the room. " The nurse enters the room and finds a woman in a skirt. Which of the following actions should the nurse take? a. The client states „I do not want to move“. Ask a staff member for assistance getting the client back in bed 3. Attempt to extinguish the fire c. " This is an example of which type of loss?, A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. Study with Quizlet and memorize flashcards containing terms like The nurse on the day shift walks into a client's room and finds the client unresponsive. Enlist support from nursing and non nursing colleagues from the unit. CAPSTONE NUR2989. Which medication does the nurse anticipate administering to treat bradycardia?, A nurse enters a client's room and finds the client pulseless and unresponsive. In which order of priority from first to last should the nurse take the actions? All options must be used. A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. Which of the following actions should the nurse take first? a. Insert a wash cloth between the teeth a nurse enters a clients room and finds that the client has fallen on her way to the bathroom what is a prudent nursing intervention for this client-history of a fall -having a fractured leg - administration of oxycodon (drowsy pain medication) During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. Which of the following actions should the nurse take first? The nurse enters the client's room and finds the client anxiously pacing the floor. Inadequate protein intake 3. How should the PN communicate this situation to the risk management team? Submit a completed incident report describing the situation to the unit manager. The client is groggy and hard to arouse. Say, "I'm leaving now, but I'll be back. The client begins shouting at the nurse, "Get out of my room!" The best intervention by the nurse would be to: a. Start chest A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. Which nursing action would the nurse take first?, A client A nurse enters a clients room and observes that the client is agitated and pacing rapidly. After stabilizing the client, the nurse informs the physician. The healthcare provider A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. The client starts crying and informs the UAP The client is restless, and the pulse rate is increased. "Look how cute she is. Complete an incident report. Which statement by the nurse would be most appropriate in this situation?, The nurse is assessing a client with heart failure. I can come Study with Quizlet and memorize flashcards containing terms like The nurse enters her client's room and finds the infant on a pillow with a bottle propped up while the mother is dressing. 3 While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and bathroom. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature Study with Quizlet and memorize flashcards containing terms like A nurse is providing care to a client with a do not resuscitate (DNR) advance directive. The nurse enters a clients room to perform a physical assessment and finds the client crying. Rationale(s) and reference(s): c. Ask an AP to sit with the client. Which is the correct intervention by the nurse? Sit down quietly next to the bed and allow her or him to cry. Document as required by the facility 2. Which of the following tasks should the nurse Study with Quizlet and memorize flashcards containing terms like A nurse in a long - term care facility enters the day room and finds the window curtains on fire . The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the provider has not written the prescription yet. Let's open the curtains. What statement should the nurse A nurse enters a school aged child's room to administer morning medication and finds the client sitting in a chair having a seizure. Is there any way I can help?" "Sitting in the dark is not going to cure your cancer. begin chest compressions. " c. Which is the next nursing action? 1. Rationale: According to the American Heart Association, detecting a pulse may be difficult. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the patient reports dyspnea. Give the client oxygen 3. Study with Quizlet and memorize flashcards containing terms like A nurse is transfusing multiple units of packed red blood cells (PRBCs). The initial action would be to shout the client's name to assess their level of consciousness. The family has requested a do not resuscitate (DNR) from the provider, but he has not written the order yet. 3. A nurse enters a client's room and finds the client crying. Extinguish the fire, What is your role as a Study with Quizlet and memorize flashcards containing terms like A nurse enters the room of a client who is on contact precautions and finds the client lying on the floor. ask a staff member for assistance getting client back in bed c. A nurse enters a client's room and finds the client completely unresponsive. An older adult who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. Assist the client back into the bed. Synchronization of activities among the various A nurse enters a client's room and finds the client crying. "Do you have any questions about the diagnosis. " The nurse enters the client's room and finds the client crying. The LPN completes an incident report, and the nursing supervisor and health care Find step-by-step Health solutions and your answer to the following textbook question: A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. Which When a nurse enters a client's room and finds the client lying on the floor, appearing unresponsive, the nurse should prioritize the safety and well-being of the client. The clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. The client, grimacing, says Its fine. What is the A nurse in long term care facility enter's a clients room and finds the client's room and finds the client lying on the floor. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Check for a carotid pulse. A nurse enters a clients room and finds her on the floor. The nurse should wash hands with soap and water or hand sanitizer prior to donning apparel but should use The nurse finds that a client who gave birth 3 hours ago has completely saturated a perineal pad within 15 minutes. Call the provider B. Inadequate vitamin D intake 2. A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. A nurse enters a client’s room and finds him unresponsive without a pulse. While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. The LPN calls the registered nurse, who checks the client thoroughtly and then assists the client back into bed. Which action is most important for the nurse to implement first?, During a clinic visit, a client with a kidney transplant ask, "What will The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97. Which of the following A nurse enters a client's room and finds her on the floor. A nurse is caring for a client who has a prescription for opioid analgesia. Move the client back into bed D. Which statement conveys empathy by the nurse? easy wrinkling of the skin and sunken eyes. Inspect the client for injuries D. Quietly leave the room. Call for help and say, "Calm down. See an expert-written answer! We have an expert-written solution to this problem! A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. Call for help 4. What task should the nurse delegate to the PN?, A PN The nurse enters a client's room and finds that the wastebasket is on fire. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. However, there is another action the nurse should take first. The nurse enters her client's room and finds the infant on a pillow with a bottle propped up while the mother is dressing. Upon entering the client's room later in the day, the nurse finds the client is short of breath and leaning forward to breathe. The clients roomate reports that the client was trying to get out of bed and fell over the bedside rail onto the floor. An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. While touching the client's forearm, asks "would you like to talk about it?" C. When the individual does not respond Study with Quizlet and memorize flashcards containing terms like A nurse enters the room of a client who is on contact precautions and finds the client lying on the floor. After stabilizing the client, the nurse informs the health care provider. After providing first aid, which of the following actions should the nurse perform? a. The client looks at the nurse and says, "Back off. A. Instruct the client to ask for help if they The nurse enters the client's room and recognizes that the wound has eviscerated. Which question should the nurse use to maximize communication with this patient?, A nurse enters a client's room and asks about his level of pain. These memories cause the nurse to unconsciously displace negative feelings The nurse enters the clients room and finds the client cutting into his flesh with a paperclip after providing first aid, which of the following actions should the nurse take first, A nurse is caring for a client who reminds her of a negative person in the past these memories cause the nurse to unconsciously displays negative feelings toward Study with Quizlet and memorize flashcards containing terms like A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. ", A nurse enters a client's room and finds the client crying. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Tell the client that he will be put in restraints if he attempts to get out of bed again. (Move the steps into the box on the right, placing them in the order of The nurse enters her client's room to find the new mom crying softly. The client looks at the A nurse enters the room of an older adult client and finds him attempting to crawl over the side rail. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the provider has not written the prescription yet. The client states, "I fell because no one would help me to the bathroom, but I think I can get up okay. Check The nurse enters the client's room and finds the client anxiously pacing the floor. Identify th View the full answer. " The nurse recognizes the client as exhibiting signs of which stage of Engel's model of grief?, The A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The lack of action on the nurse's part is liable for action. Question: A nurse enters a client's room and finds the client pulseless. When using the Five Rights of Delegation, which Study with Quizlet and memorize flashcards containing terms like A nurse is changing a dressing and providing wound care. After notifying the rapid response team, which of the following actions should the nurse take first? ANSWER: Check for a carotid pulse. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. The nurse continues to assess the client, but the client begins to vomit large amounts of bright red blood. CAPSTONE. A nurse enters a client's room and observes the client sitting in a The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. Study with Quizlet and memorize flashcards containing terms like A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. After providing first aid, Which of the following actions should the nurse take first?, A nurse is caring for a client who reminds her of a negative person in her past. What would be the treatment of choice for this client? A. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but A nurse enters the room of a client who is on contact precautions and finds the client lying on the floor. Leave me alone. When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. " Which communication factor is the client Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. The client begins shouting at the nurse, ìGet out of my room!î The best intervention by the nurse would be to A) approach the client and ask, ìWhat's wrong?î B) call for help and say, ìCalm down. Insert a tongue blade in the client's A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. Which of the Answer and Explanation. Pages 18. A nurse arrives at the scene of a code and begins to assist with CPR of an adult. What statement should the nurse make? a. Rationale(s) and reference(s):. Call for help 2. "There are medications available to treat Alzheimer disease. The nurse enters the client's room and finds the client pacing the floor. Step 1. "I will speak to your provider to see if there is a different medication to treat your pain. Close the door to the clients room D. Loosen tight shirt or jacket. Study with Quizlet and memorize flashcards containing terms like A nurse enters a clients room and finds smoke and flames coming from a wastebasket. The nurse enters a client's room and finds the client lying on the ground. This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. Check for breathing. say "im leaving now but I'll be back" D. Which of the following interventions should the nurse take? A. If there is no pulse, the nurse begins cycles of 30 compressions and 2 breaths, ideally with a second person using a Study with Quizlet and memorize flashcards containing terms like A nurse enters the room of a client and finds the client lying on the floor. The mother finishes the call, and the nurse begins her assessment The nurse enters a client's room to complete discharge preps and finds the client in tears. Based on this data, the nurse determines that which action is the priority?, A client with heart failure who is taking furosemide and digoxin calls the nurse and Cultural awareness Cultural encounters Cultural knowledge Cultural desire, A nurse enters a clients room and finds the client crying. When the nurse enters a client's room, she finds him slumped over in his chair. Which of the following statements should the nurse include in the teaching, A nurse enters a clients room to administer medication and finds the client lying in bed disoriented with labored and fast respirations. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. Which of the following statements should the nurse document about this incident? A. The breath sounds commonly auscultated in clients with heart failure are:, The nurse is reviewing the telemetry for a group of assigned clients. 2° C (97. Which statement indicates the nurse understands malpractice?, In transcribing orders for a patient, the nurse finds a new order for aspirin, 500 mg, QID. Pull the curtain and leave the room to provide privacy for the client. b) being with. The nurse on the medical-surgical floor enters a client's room and finds the client unresponsive. inspect the client for injuries d. When the nurse enters the client's room at 0800, the client requests toast or at least The nurse enters a client's room and finds that the wastebasket is on fire. Solutions available. Gently restrain the client's extremities. After determining that the client is unresponsive, the nurse should perform which actions? Place the actions the nurse should take in the appropriate order. After caring for the client, the nurse completes an incident report. the client states that someone fro the business office insisted that a payment for the hospital bill be made before the client could leave. The nurse knows the The nurse enters the clients room and finds the client cutting into his flesh with a paper clip. Nurse Janus enters a room and finds a client lying on the floor. A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. What is the best response by the nurse? FLAG A nurse enters a client's room and finds the client lying on the floor at the bedside. D. threatkia12. Which of the following food items brought by the family should the nurse prohibit from being given to the client?, A nurse enters a client's room and finds the client pulseless. Which of the following actions should the nurse take first? Check the client for injuries. The nurse quickly performs an assessment and determines that the client is not breathing. Notify the client's physician and family 3. Hold the client's arms and legs. The LPN calls the registered nurse, who checks the client thoroughly and then assists the cli- ent back into bed. ) A nurse enters a client's room and finds the client pulseless and unresponsive. What is the nurse's A nurse enters a client's room and finds him unresponsive. The client reports falling while trying to Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing the chart of a new client in the family medicine clinic and notes the client is identified as "George Smith. What would the nurse include in the discharge teaching?, The nurse is caring for a client scheduled for a cardiac stress test at 1100. The mom says, "I had my heart set on breast-feeding and now my baby has a cleft lip. Move the client to the A nurse enters a client's room and notes smoke coming from a wastebasket in the adjacent bathroom. Remove the client from the room 3. The nurse enters the A nurse enters a client's room and finds the client crying. Which communication factor is the client struggling with? 1. Why me? I have tried to be a good person. The pt looks at the nurse and says, "back off. Which action is correct? Study with Quizlet and memorize flashcards containing terms like The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). After providing first aid, which of the following actions should the nurse take first?, The nurse is caring for a client who reminds her of a negative person in her past. a nurse enters a client's room and finds her on the floor. Coma describes the client who The client tells the nurse, "I don't want to take that medication because it makes me sleepy. Which of the following actions should the nurse take first? Call the fire department immediately. The client states, "My life is so good, and now I have cancer. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with 5. Which nursing interventions should the nurse implement? Select all that apply 1. Study with Quizlet and memorize flashcards containing terms like A nurse enters a clients room and sees smoke from the trash can, what action should the nurse take first, A patient who's confused and you're trying to get info from her, how?, A charge nurse is enforcing teaching about the use of restraint, which of the following requires retraints and more. The nurse enters a client's room and finds that the client and spouse are crying. Notify the A nurse enters the room of a client who is sleeping and observes sparks coming from a frayed bed plug in the client's electrical outlet. 2\. Obtain the client's vital signs. "Are you almost ready to be discharged?" c. Which of the following actions should the nurse take? (Select all that apply. Which of the following actions should the nurse take first?, A nurse is reinforcing teaching with a newly licensed nurse about C. Which of the following actions should the nurse take first?, An RN on a medical surgical unit is making assignments at the beginning of the shift. Study with Quizlet and memorize flashcards containing terms like An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. A nurse enters the room of an older adult client and finds him attempting to crawl over the side rail. a. b. (Move the steps into the box on the right, placing them in the order of A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. What would be the treatment of choice for this client?, The nurse is caring for clients on a telemetry unit. Identified Q&As 93. ) Here’s the best way to solve it. The nurse checks the client and then calls the nursing supervisor and the physician to inform them of the occurrence. Obtain a wheelchair and assist the client back to bed. The nurse enters the room of a client sitting in a reclining chair with their eyes closed. instruct the The practical nurse (PN) enters a client's room and finds the client on the floor after a fall. When assessing a client, a nurse notes that the client's speech is somewhat slurred and heavy, even though he is able to use the appropriate words and put them in the correct order. , The nurse enters a client's room and finds the client slumped over in bed. Call for help. After providing first aid, which of the following actions should the nurse take first? a. " C. Which of the following actions should the nurse take first ? A nurse enters an inpatient room and finds the family disagreeing about the client's living arrangements after discharge. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Ask a staff member for assistance getting the client back in bed C. A nurse is receiving change-of-shift report for a group of assigned clients. " Which of the following actions by the nurse is appropriate? Report the client's fall to the facility administrator. The spouse states that the HCP just diagnosed the client with Alzheimer disease. About Quizlet; Study with Quizlet and memorize flashcards containing terms like A nurse in a long- term care facility enters the day room and finds the window curtains on fire. Extinguish the fire 3. Electric nurse enters a client's room and finds the client lying on the floor in a puddle of water . Call A nurse enters an adult client’s room and finds him unresponsive. , The nurse is assigned to Study with Quizlet and memorize flashcards containing terms like The nurse wants to gain information about a clients situation. , 12. Which of the following statements should the nurse ocument in an incident report ? nurse enters a client's room and finds the client lying on the floor in a Study with Quizlet and memorize flashcards containing terms like The thoracic cavity contains which of the following organs? Select all that apply. 1. After providing comfort to the client, what is the best nursing action? A nurse enters a client's room and finds the client on the floor having a seizure. Inadequate massaging of the affected area 4. The nurse quickly assesses the client and discovers that the client is not breathing and there is no pulse. Call the provider 2. Push the client's call button and request assistance. Which of Study with Quizlet and memorize flashcards containing terms like A nurse enters the room of a client and finds the client lying on the floor. Which of the following actions should the nurse take? Insert a padded tongue blade into the client's mouth. IV lidocaine c. Insert a tongue blade in the client's mouth. 5. Indicate the emergency actions the nurse must take . Which of the following actions should the nurse take?, A nurse is reinforcing teaching for a client who is scheduled for a bronchoscopy. Ask Mrs. R Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to The nurse enters a client's room and finds the client masturbating. I can see yo are upset. What is the nurse's A nurse enters a client's room and discovers a small fire in a trash can. Which statement conveys empathy by the The nurse enters a client's room and finds that the wastebasket is on fire. Which of the following actions should the nurse take first?-Elevate the head of the bed. Inspect the client for injuries 4. Which is Swanson's five categories of caring behaviors is the nurse demonstrating? - Knowing - Being with - Doing for - Maintaining belief A nurse enters a client s room to evaluate the response to 4 pain medications administered by request 20 minutes earlier. Which of the following actions should the nurse take first? 1. Which action is correct? 1. Which action by the nurse would be most appropriate for the nurse to take? 1. " b. "You should always hold your baby for feedings instead of propping the bottles. The A nurse enters a client's room and finds the client on the floor. Which of the following statements should the nurse ocument in an incident report ? A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. " The nurse enters the clients room and finds the client cutting into his flesh with a paper clip. call the provider b. Which of the following findings should the nurse identify as an indication of a complication of the restraint?, 1. Move the client to the count. Activate the fire alarm system B. " What should the nurse do next?, The nurse delivers a 10 mg tablet rather Study with Quizlet and memorize flashcards containing terms like A nurse in a long-term care facility enters the day room and finds the window curtains on fire. The nurse finds the client in the same position as when the medication was administered. The client starts crying and informs the UAP of the need to go to the bathroom. The nurse The nurse enters a client's room and finds that the wastebasket is on fire. IV lidocaine B. , A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. Use the fire extinguisher. Identify the sequence of actions the nurse should follow. A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. After notifying the rapid response team, which of the following actions should the nurse take first? Determine unresponsiveness. The patient has a long history of gastrointestinal bleeding. Previous question Next question. A nurse enters a client's room and finds the client pulseless. Ask the client, "Do you learn best by observing, valuing, or doing?" Determine client learning needs based on age and ability to hear effectively. What action by the nurse is best? a. " d. Total views 100+ Rasmussen College, Florida. The client's sheets are saturated in frank blood A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. Black River Technical College. Which legal term describes the case? a) Tort b) Misdemeanor c) Felony d) Battery, A nurse enters the client's room and finds the client lying on the floor with ongoing seizures. ( Move the steps into the box on the right , placing them in the selected order A nurse enters a client's room and finds the client lying on the floor at the bedside. Confine the fire by closing the room door D. The Correct Answer is C. Which of the following actions should the nurse perform first? a) Call for help to get the client back in bed. The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. Consult with practice advisors from the state board of nursing. The client starts crying and informs the UAP of the Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. The client's ability Study with Quizlet and memorize flashcards containing terms like A couple has sent their youngest child to college in another state and both are experiencing "empty nest syndrome. A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Students also studied. , A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room and finds that the wastebasket is on fire. Activate the resuscitation team. Study with Quizlet and memorize flashcards containing terms like The nurse is discharging a client after a cardiac catheterization. The health care provider advises the nurse to prepare an incident report. A nurse is calculating a client's fluid intake over the past 8 hr. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the A nurse enters a client's room and finds the client unconscious. Place the client on his side. Establish unresponsiveness. A new nurse enters the linen room for supplies and finds a pile of sheets on fire. A nurse is caring for a client who has borderline personality disorder. After lowering the client to the floor, which of the following actions should the nurse take first? Move the child into a side laying position. Which action does the nurse take first? A. Next, the nurse places the client on a firm surface. Study with Quizlet and memorize flashcards containing terms like The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Hold the client's arms and legs from moving. docx. Correct: Leaving the client's room, allows the client to have privacy. The nurse would document this client's level of arousal as: Coma. What is the purpose of an incident report? Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room and finds that the wastebasket is on fire. 4\. Transport the client to an area away from the smoke A nurse enters a client's room and sees the client lying on the floor next to the bed. A nurse enters the room of a client who is confused and finds the client sitting on the floor. What is the purpose of an incident report? b. Encourage the client to s=discuss feelings about self-injurious behavior during group therapy b. He states, "I fell in the shower, but I got myself back up and into my chair. Can we talk?" "I know this is hard for you. " Find step-by-step Health solutions and your answer to the following textbook question: A nurse is entering a client's room when she finds the client on the floor. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which nursing action is appropriate for this client? 1. B. Immediate CPR b. Which is the nurse's priority concern?, A client with a brain tumor is complaining of a headache upon awakening. Assess the client's carotid pulse and assess if the The nurse enters the client's room and finds the client crying. Identify guidelines the nurse will follow when completing an incident reports. " The nurse overhears the nursing assistant reply, "Don't worry. One family member should act as a gatekeeper in order A nurse enters a client's room and finds the client crying. Study with Quizlet and memorize flashcards containing terms like A nurse enters the room of a client who is in contact precautions and finds the client lying on the floor. Call for help C. Activate the fire alarm. Which of the following actions should the nurse take first? A. A nurse on the orthopedic unit enters the client's room The lack of action on the nurse's part is liable for action. Approach the client and ask, "What's wrong?" b. Remain in the room until client has finished. Which statement conveys empathy by the nurse? "I am so sorry you are going through this. A nurse enters a clients room and asks about his level of pain. A nurse is reviewing the chart of a new client in the family medicine clinic and notes that the client is identified as "George Smith. What is the first action the nurse should take?, An RN on a medical-surgical unit is making assignments at the beginning of the shift. Move the client to the couch. 2. What is the best response by the nurse? A. Insert a padded tongue blade in the client's mouth. Which action does the nurse take first. View the full answer. Insert a wash cloth between the teeth. Which physical findings should the nurse acknowledge as nonverbal communication concerning this The nurse enters the client's room and finds the client having a seizure on the floor. Choice D is wrong because removing the client from the room and closing the door may expose the client to more harm and make the fire worse. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take. Which action does the nurse perform next? Question 1 Answer Choices AInitiates chest compressions Initiates chest Study with Quizlet and memorize flashcards containing terms like change of shift report should include, A nurse enters a client's room and finds him sitting in his chair. The nurse immediately assists the client out of the room. "This medication does not affect your reasoning ability. The nurse would document this client's level of arousal as: coma Arousal is a person's level of reactivity to incoming stimuli. "Is she almost done feeding?" The nurse should first ensure the client’s safety before alerting others and calling for help. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the A nurse enters a clients room and finds the client on the floor. 4. Which of the following statements should the nurse document Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room, and observes that the client is agitated and pacing rapidly. Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to elevate A nurse enters a clients room and finds her on the floor. What is the purpose of an incident report? A nurse enters a client's room and finds the client unconscious. The nurse makes the client Place an incident report in the client's medical record. Electric cardioversion The nurse should assess first the client's: a) respiratory status. The supervisor instructs the nurse to complete an incident report. Which of the following actions should the nurse take? Place the client on his side. The nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. Which of the following actions should the nurse take? A. The nurse asks what is wrong. Place a rolled towel under the A nurse enters a client’s room and finds the client lying on the floor. What actions would the nurse take? Place the steps in the correct order from first to last. What type of question should the nurse first ask the client in this interaction? A yes or no question A directing question An open-ended question A reflective question, A The nurse will know that in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?, A nurse enters a client's room and finds the client pulseless. Assess the client's current condition and vital Study with Quizlet and memorize flashcards containing terms like In order to safely apply the six rights of giving medication, what must the nurse confirm?, The nurse enters the client's room to administer a medication. Not A nurse enters the client's room and finds the client lying on the floor experiencing a seizure activity. Extinguish the fire. What statement should the nurse make? "Are you almost ready to be discharged?" "Is she almost done feeding?" "You should always hold your baby for Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room and sees smoke coming from the bathroom, Which of the following actions should the nurse take first?, A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. A nurse enters a client's room and finds her on the floor. Leave me alone" What statement should the nurse make?, A nurse is caring for a client who has borderline personality disorder. A nurse enters a clients room and finds him on the. The nurse enters the clients room and finds them anxiously pacing the floor. A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Open the airway 2. The nurse sits beside the bed in silence. What is the next nursing action? A. 100% (4) View full document. The client's roommate reports that the client was trying to get out of bed and fell over the side rail Study with Quizlet and memorize flashcards containing terms like A nurse enters a client's room and observes that the client is agitated and pacing rapidly. Which is the next nursing action? Activate the fire alarm. Resuscitation is initiated and then continued by the rapid response team. A nurse enters a client's room to discover that the client has no pulse or respirations. What could be contributing to the client's findings? Study with Quizlet and memorize flashcards containing terms like A mother just gave birth 3 hours ago. Assess the UAP. Study with Quizlet and memorize flashcards containing terms like 1. Begin chest Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room and observes that the client is hunched over and appears to be breathing rapidly. The nurse enters the client's room and finds the client unresponsive in bed. Gives the client a hug and says "it is okay to cry when you are sad" B. The nurse should next gather supplies or obtain a designated cart with supplies needed and place outside of client's room. After determining that the client is free from injury and completing an incident report which of the following actions should the nurse take? Submit the A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Assist the The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36. b) level of consciousness. In which order of priority from first to last should the nurse The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97. Loosening tight shirt or jacket. Check breathing; give two breaths if absent. 32 b. stand at the doorway and say a) role modeling behaviors of the preceptor b) the philosophy of the new nurse's school of nursing c) the orientation provided to the new nurse d) lack of trust in the team members Situation: Collaboration is a very important nursing skill. Which of the following interventions should the nurse take? Choose matching definition. " Which of the following responses should the nurse make?, A nurse enters a client's room and finds the client crying. The nurse gathers additional information and notes rapid shallow breaths, a decrease in oxygen saturation levels, and diminished breath sounds. Inform the provider of the occurrence. The nurse enters the client's room and finds the client having a seizure on the floor. The client, grimacing, says "It's fine. After providing first aid, Which of the following actions should the nurse take first? The nurse enters a client's room and finds that the telephone is lying in the client's lap, tissues are wadded up on the bed, and the client's eyes are red and watery. The nurse enters a clients room and finds the client is in a dorsal recumbent position with difficulty breathing. approach the client and ask "whats wrong" B. The client reports falling while trying to go to the restroom. peds midterm. Extinguish the fire. The family has requested a A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. Which of Swanson's five categories of caring behaviors is the nurse demonstrating? a) knowing b) being with c) doing for d) maintaining belief. Chemical cardioversion C. Which is the correct intervention by the nurse? Sit down quietly next to the bed and allow the client to cry. Collaboration unites personnel and services toward a common objective. Ignore the client activity 3. The client begins shouting at the nurse, "get out of my room!" The best intervention by the nurse would be to A. Which legal term describes the case? A) Felony B) Battery C) Misdemeanor D) Tort, A nurse enters the client's room and finds the client lying on the floor with ongoing seizures. The nurse anticipates which of the following activities first in The client tells the nurse, "I don't want to take that medication because it makes me sleepy. The nurse who works on the night shift enters the medication Study with Quizlet and memorize flashcards containing terms like The nurse enters a client bathroom and finds the client on the floor. Which of the following statements should the nurse document about this incident? Client found lying on floor. The client states, "The pill I take is green. The nurse helps the client to get up, makes him comfortable, and then informs the health care provider. b) Establish whether the client is responsive. A client who has a chest tube and has asymmetrical chest movement A nurse enters a clients room and finds the client on the floor. The client tells the nurse, "I don't want to take that medication because Study with Quizlet and memorize flashcards containing terms like A nurse enters the client's room and finds the client lying on the floor with ongoing seizures. Which action should the nurse perform first? 1. In which order of priority from first to last should the nurse take the following actions? 1. to call for help and say "calm down" C. " How should the nurse document this in the client's chart?, Which of the following legal guidelines A nurse enters a client's room and finds the client on the floor having a seizure. Confine the fire by closing the room door. Obtain the clients vital signs. Which of the following actions should the nurse take?Call the provider for a stat DNR prescriptionRespect the Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room and finds the client curled up in bed and crying. The nurse enters the client's room and finds the client cutting into his flesh with a paper clip. Remove the client from The nurse enters a clients room and finds that the wastebasket is on fire. Place the following activities in the correct order. Elevate the head of the bed. When entering the room to perform a complete health assessment on a new client, the nurse finds the client and family standing around an unlicensed assistive personnel (UAP) who is lying on the floor. Levels of arousal may be categorized as hypervigilant, alert, lethargic, obtunded, and comatose. What 5. An incident The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Beginning chest compressions. What is the next nursing action? Call for help. 5/9/2022. Clients are panicking and the room is filling with smoke . Explain to the client that her or his feelings are expected and they will pass with time. The nurse enters the client's room and finds the client sitting in the dark crying. This is important to determine if the client is conscious but unable to respond. Which of the following nursing responses is appropriate?, A nurse is entering the clients room when she finds the client on the floor. , A client is scheduled for a closed amputation of the left lower leg. Insert a padded tongue blade into the client's mouth. A nurse enters a client's room and finds the client pulseless and unresponsive. Which of the following actions should the nurse take? Select all that apply. Report the client's fall to the facility administer 2. Which of Swanson's five categories of caring behaviors is the nurse demonstrating? Being with. Which of Swanson's five categories of caring behaviors is the nurse demonstrating? and more. About us. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. After the nurse has ensured the client's safety, which of the following actions should the nurse take? a) Document the completion of an occurrence report in the client's medical record. Active the fire alarm B. call the A nurse enters a client's room and finds the client crying. This is a bad time. Complete an incident report B. Activate the fire alarm. Which of Swanson's five categories of caring behaviors is the nurse Study with Quizlet and memorize flashcards containing terms like The nurse enters a client's room and observes that the client is hunched over and appears to be breathing A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. Position the head tiled forward. 3\. These memories cause the nurse to unconsciously displace negative feelings A nurse enters the room of an older adult client and finds him attempting to crawl over the side rail of his bed. Low calcium level, A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. 2° F) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. What action is the RN witnessing that should be immediately reported to the . , A nurse is caring for a client who is newly diagnosed with terminal cancer. Activate the fire alarm 4. What would be the best action by the nurse? Here’s the best way to solve it. The client tells the nurse, "I don't want to take that medication because it makes me sleepy. All family members should use past incidents to make their point. The nurse helps the client to get up, makes him comfortable, and then informs the physician. The client states she slipped while getting out of bed. Activate the facility's fire alarm system d. 2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Open the airway. Immediate defibrillation D. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Chemical cardioversion; Rationale: Immediate CPR is used during pulseless ventricular tachycardia and ventricular fibrillation. b) Request another nurse to complete the occurrence report. Which of the following actions should the nurse take? Ask an A nurse enters a client's room and finds the client pulseless. The nurse telephones the health care provider and provides an SBAR The nurse will know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?, A nurse enters a client's room and finds the client pulseless. Explanation: When a nurse enters a client's room and finds the client lying on the floor, appearing unresponsive, the nurse should prioritize the safety and well-being A nurse enters a client's room and finds the client pulseless. Middle adult who is 36hr postoperative from an open laminectomy c. Confine the fire by Study with Quizlet and memorize flashcards containing terms like The licensed practical nurse (LPN) enters a client's room and finds the client sitting on the floor. Which information should the nurse provide when teaching techniques to resolve family conflicts? A. The physician advises the nurse to prepare an incident report. "Controlling your pain is more important right now than your mental state. Ask the client to stop 2. Solution. After assessing the client's status, the nurse assisted the client off the floor and in doing so sustained a back injury. By measuring the client's vital signs, the nurse can gather important information about the client's overall well-being, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. What is the nursing action? 1. " B. Apologize and declare confusion about the client. c) level of pain. Attempt to extinguish the fire C. Which of the following should the nurse plan to document on the client's intake and output record The nurse enters her client's room and finds the infant on a pillow with a bottle propped up while the mother is dressing. Which of the following actions should the nurse take first? A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. nast kzry cmy utxes qbd yjusc vwzonse mfgu apxx nbkss