comprehensive

A postoperative patient has been receiving opioid analgesics for pain management. The patient reports a sudden increase in pain intensity and requests more pain medication. The nurse observes facial grimacing and restlessness. What is the nurse's immediate action?

• Administer an additional dose of the prescribed opioid medication.

• Assess the patient's vital signs before administering more medication.

• Contact the provider to advocate for an alternative pain management plan.

• Assist the patient to practice guided imagery and reposition for comfort.

What do you notice as abnormal or unexpected? Begin to interpret your findings.

What additional assessments should you make?

What is the ONE priority NANDA-I label? Write a complete PES statement.

Write one Goal (broad) and one Expected Outcome (SMART).

Identify 2 priority nursing interventions to meet the goal and EO you stated in the previous question.

How and when would you evaluate the patient’s response to the intervention?

A nurse is caring for a terminally ill patient who has expressed a wish to discontinue life-sustaining treatments. The patient's family, however, disagrees with this decision and insists on continuing aggressive interventions. What action should the nurse prioritize in navigating this ethical and legal dilemma?

• Follow the family's wishes as they are the primary decision-makers.

• Seek guidance from the hospital's legal team to override the family's concerns.

• Advocate for a family meeting to discuss the patient's wishes and explore potential compromises.

• Notify the healthcare provider to make the final decision on the course of treatment.

A nurse is caring for a client who is alert and oriented with advanced heart failure. What factor(s) should be considered when determining if hospice care is appropriate for this client? Select all that apply.

• The patient's prognosis and life expectancy.

• The availability of financial resources for long-term care.

• The patient’s goals and personal opinions about hospice.

• The frequency of the patient’s healthcare provider visits.

• The patient’s ability to manage activities of daily living (ADLs).

A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer’s disease and has been incontinent of urine. The nurse inserts a Foley catheter. What is the most significant risk for a Health Care Associated Infection (HAI)?

• Restraints.

• Poor dental hygiene.

• Foley catheter bag.

• Improper positioning of patient.