A patient with emphysema enters the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26 . After positioning the patient in high Fowler's, the nurse should:
a. attempt to help the patient slow her respi-rations.
b. coach in pursed-lip breathing.
c. give oxygen at 5 L/min by nasal cannula.
d. reposition patient in orthopneic position.
B
Coaching in pursed-lip breathing will open the respiratory tree with negative pressure. Oxygen given at such a high concentration will cause an emphysemic patient to stop breathing. High Fowler's position is beneficial and easy to position with minimal equipment.
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Which statement demonstrates appropriate communication techniques by the student nurse in maintaining a therapeutic relationship with the client?
a. "I need to ask you a lot of questions about your health so that I can complete my paperwork." b. "I want you to use your incentive spirometer at least Q2H while awake, to deep breath and cough. You can call me if you need any help." c. "I'll need to get a blood sample from your finger, in order to check the amount of sugar in your blood." d. "I'm wondering if you knew that your doctor had scheduled you for a test tomorrow? You don't have any questions about the procedure, do you?"
The nurse understands that an expectorant is administered cautiously to a client with which condition?
A) Renal impairment B) Persistent headache C) Persistent cough D) Seizure disorder
An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?
a. Urine output of 25 mL/hr b. Heart rate of 110 beats/minute c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat
A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.)
a. Head of bed elevation to 90 degrees at all times b. Daily oral care with chlorhexidine c. Cuff monitoring for adequate seal d. Clean technique when suctioning e. Daily "sedation vacations" f. Heart failure prophylaxis