A charge nurse would appropriately intervene if she heard a nurse under her supervision say:
1. Ms. Anderson, it sounds like in addition to your abdominal pain, you have an irregular heartbeat. Have you ever had this before? It's important to check your pulse if you have any abnormal feelings in your chest, and if your pulse feels irregular, you should call your doctor right away.
2. Mr. Sanchez, my name is MaryAnn. Can you repeat my name back to me? No, that's not righttry again. No, that's not how you pronounce itit's MARY ANN. Can you say that? No? I think you may be having a stroke.
3. Mr. Allen, it seems you're having rebound tendernessmeaning increased pain after I apply pressure to your abdomen and then release the pressure. That's a possible sign of appendicitis. Have you had your appendix removed?
4. Mrs. McBain, have you experienced numbness in your feet before? Really, how often? The reason I ask is that it can be a sign of diabetes or other serious illnesses like multiple sclerosis. Have you ever been tested for diabetes or MS before?
Question 2
In a postoperative assessment of a patient who has had knee replacement surgery, the nurse notes that the patient is experiencing moderate knee pain and somewhat slurred speech.
The nurse appropriately
1. Checks the patient's chart to determine whether her slurred speech can be attributed to her postoperative medications and, if not, summons her doctor to determine whether she is having postoperative complications.
2. Asks the doctor to adjust the patient's pain medications to relieve the pain and prevent any further slurring of speech.
3. Asks the patient to let the nurse know if the pain or the slurred speech gets worse, then reassesses the patient's symptoms in 4 hours.
4. Calls the patient's doctor immediately because she may be suffering a stroke because of a blood clot that traveled from her legs postoperatively.
NURSE
A, A nurse is adding a medication to an IV line as a piggyback
The nurse cares for the postop client in the postanesthesia care unit (PACU).
Nurse examining and measuring hematuria sample from client with a UTI
Nurse Sandy
Nurse administering enteral nutrition through a feeding tube.