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1、Lucas Lucas luksAmy Amy 英英 em 美美 em Anderson ndsngo over to go over to 朝朝走去走去BoothBooth bu n. n. 貨攤;公用電話亭貨攤;公用電話亭counter counter kantn. n. 柜臺;對立面;計數(shù)柜臺;對立面;計數(shù)Emergency Medical Treatment and Labor Act = EMTALA緊急醫(yī)療護理與勞動法http:/ assessment of victimsClassify victims according to the severity of severity

2、of the injury, urgency of treatment, and place the injury, urgency of treatment, and place for treatmentfor treatmentHighHigh Life-threateningLife-threatening Result in harm if untreatedResult in harm if untreatedIntermediateIntermediate Nonemergency Nonemergency Non-life-threatening client needsNon

3、-life-threatening client needsLow Low Needs that are not related directly to clients illness Needs that are not related directly to clients illness or prognosisor prognosisActual concerns potential concerns ABCABC: Airway maintain patent airway! Breathing CirculationMaslows Hierarchy of needs: Physi

4、ological need Safety Love and belonging self-esteem self-actualizationNursing process Assessment first1.A client with heart failure who has a 4-ib weight gain since yesterday and is experiencing shortness of breath2.A 24-hour postoperative client who had a wedge resection of the lung and has a close

5、d chest tube drainage system3.A client admitted to the hospital for observation who has absent bowel sounds (腸鳴音消失)4.A client who is undergoing surgery for a hysterectomy (子宮切除術(shù))of the following dayIf u are a first responder at the scene of a school bus accident1.Confused child with bright red blood

6、 pulsating from a leg wound2.Child with a closed head wound and multiple compound fractures of the arms and legs3.Child with a simple fracture of the arm complaining of abdominal pain4.Sobbing child with several minor lacerations on the face, arms, and legsU are assigned to care of four clients.In p

7、lanning client rounds, which comes first?1.A client scheduled for a chest x-ray2.A client requiring daily dressing changes3.A postoperative client preparing for discharge4.A client receiving nasal oxygen who had difficulty breathing during the previous shift1.A client who is ambulatory2.A client sch

8、eduled for physical therapy at 1 pm3.A client with a fever who is diaphoretic and restless4.A postoperative client who has just received pain medication1.A client complaining of muscle aches, a head-ache, and malaise2.A client who twisted her ankle when she fell while rollerblading3.A client with a

9、minor laceration on the index finger sustained while cutting an eggplant4.A client with chest pain who states that he just ate pizza that was made with a very spicy sauceA nurse is giving a bed bath to an assigned client when a nursing assistant enters the clients room and tells the nurse that anoth

10、er assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following?1.Finish the bed bath and then administer the pain medication to the other client.2.Ask the nursing assistant to find out when the last pain medication was given to the client.3.Ask the

11、NA to tell the client in pain that medication will be administered as soon as the bed bath is completed.4.Cover the client, raise the side rails, tell the client that your will return shortly, and administer the pain medication to the other client.Dialogue 3 direct admissionConversation: patients ro

12、omDrillDrill drldrl n. 訓練Alarm Alarm lmlm n. 鬧鐘;警報,警告器Fire alarmFire alarm 火警;安全 火警警報器Realistic Realistic rlstkrlstk adj. 現(xiàn)實的;現(xiàn)實主義的;逼真的The overhead pager 揚聲傳呼器JCAHO醫(yī)療機構(gòu)評審聯(lián)合委員會Joint Commission on Accreditation of Healthcare OrganizationsClose all the doors Clear the fire exit corridorsEnsure that the

13、 exits and the evacuation routes are well lit and dont have obstaclesSet priorities in the event of a fire: RACE: RACE Rescue Rescue clients in immediate danger Alarm Alarm Contain /Confine Contain /Confine the fire by closing all doors關(guān)門限制火勢 Extinguish or evacuate Extinguish or evacuate ExtinguishE

14、xtinguishikstiwiikstiwi 熄滅Evacuate Evacuate vkjetvkjet vt. 疏散,撤退Use a fire extinguisher滅火器: PASS PASS Pull Pull the pin 拉出栓 Aim Aim at the base of the fire 對準火焰的根部 Squeeze Squeeze the handle 握緊手柄 SS: SS: sweep from side do sideConsciousness knsnsknsns n. 意識;知覺;覺悟;感覺嗜睡somnolence昏睡stupor昏迷comadelirium

15、delirium譫妄Assess the clients risk for falling.Assign the client at risk for falling to a room near the nurses station.Alert all personnel to the clients risk for falling.Assess the client frequently.Orient the client to physical surroundings.Instruct the client to seek assistance when getting up.Exp

16、lain the use of the call bell system.Use safety devices such as bed or chair alarms that alert health care personnel.Keep the bed in the low position with side rails adjusted to a safe position (follow agency policy).Lock all beds, wheelchairs, and stretchers.Keep clients personal items within their

17、 reach.Eliminate clutter and obstacles in the clients room.Provide adequate lighting.Reduce bathroom hazards.Maintain the clients toileting schedule throughout the day.A nurse hears a client calling out for help, hurries down the hallway to the clients room, and finds the client lying on the floor.

18、The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and completes an incident reportan incident report. Which of the following should be the nurse documentdocument on the incident report?1.The client fell out of bed.2.The client climbed over the side rails.3.The client was found lying on the floor.4.The client beca

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