The nurse implements the following measures for a client with rheumatic fever: turn, cough, deep breath, elevate head of bed, instruct on use of incentive spirometry
Upon which parameters would the nurse assess the effectiveness of the nursing interventions? Select all that apply. 1. Arterial blood gases
2. Lung sounds
3. Orientation
4. Urine output
5. Potassium level
1. Arterial blood gases
2. Lung sounds
3. Orientation
Rationale: Arterial blood gases. The outcome of the nursing measures is adequate gas exchange. Arterial blood gases are evaluation parameters used when assessing gas exchange. Lung sounds. The outcome of the nursing measures is adequate gas exchange. Lung sound evaluation parameters are used when assessing gas exchange. Orientation. The outcome of the nursing measures is adequate gas exchange. The client's orientation is an evaluation parameter used when assessing gas exchange. Urine output. Urine output is not a gas exchange parameter. Potassium level. Potassium level is not a gas exchange parameter.
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A nurse caring for a 9-year-old notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure, noticing a markedly slow disappearance of the indentation
Due to these physical findings, the nurse would be most concerned with assessing: 1. Skin integrity, especially in the lower extremities. 2. Urine output. 3. Level of consciousness. 4. Range of motion and ankle mobility.
The nurse is preparing to assess the general appearance of the hospitalized client. Which statements by the client are expected if the client is experiencing undernutrition? Select all that apply
1. "It seems like I catch every bug that comes along. I can't seem to stay well." 2. "This wound that I've had for the last 3 months on my leg won't heal." 3. "I have gained five pounds over the last week and my ankles and feet are swollen." 4. "My nails are so brittle." 5. "I know my blood pressure has been up because I've been experiencing headaches in the morning, just like last time."
The nurse is considering a research study for inclusion in a clinical practice guideline that has been identified as being sufficient to determine effects on health outcomes. This research study would be considered as being:
1. fair. 2. passable. 3. poor. 4. good.
The client is having a diagnostic workup for colorectal cancer. Which of the following factors in the client's history will place the client at increased risk of this type of cancer? Select all that apply
1. A high-fiber diet 2. A diet high in fats 3. Minimal alcohol intake 4. A diet high in carbohydrates 5. A history of inflammatory bowel disease 6. Maternal grandfather who had a history of heart disease