Describe four nursing interventions you will perform over the next few hours based on these priorities.
What will be an ideal response?
• Apply the oxygen per protocol, and suction orally as needed
• Elevate the head of his bed; maintain his head in neutral position
• Frequently monitor vital signs with continuous electrocardiographic and Spo2 monitoring
• Perform neurologic examination every 30 minutes to 1 hour
• Auscultate lung sounds every 1 to 2 hours
• Encourage him to deep breathe every hour
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The nurse is creating a care plan for a client who is unable to conceive as a consequence of endometriosis. Which statement accurately reflects a nursing diagnosis that may apply to the care of this client?
1. Acute pain related to dysuria and renal pain secondary to endometriosis 2. Compromised family coping related to depression secondary to infertility 3. Infertility related to endometrial inflammation and adhesions secondary to endometriosis 4. Hyperandrogenism related to elevated serum androgen levels secondary to endometriosis
The nurse suspects that a patient has vision changes caused by a stroke. What did the nurse assess to make this determination?
a. Patient asks that all items be placed on the right side of the bed. b. Patient turns head away when blood is being drawn from an arm. c. Patient looks down at the floor when sitting on the side of the bed. d. Patient does not follow with the eyes as the nurse walks around the room.
A client is complaining about the decrease in quality of life experienced since the client started dialysis. Using recent research to guide suggestions, the nurse counsels the client to
a. become more active in care planning. b. engage in regular exercise. c. start attending church if not already going. d. try to stay active in the community.
A patient has just arrived in the recovery room. As part of the evaluation for determining discharge from the postanesthesia recovery unit, what will be the nurse's next action?
1. Assess the patient's respirations, oxygen saturation, consciousness, circulation, and activity. 2. Assess whether the patient wants the family in the recovery room. 3. Assess the patient for pain. 4. Take the patient's temperature.