The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. What should the nurse do next in this situation?

1. Report the lack of achievement of the goals to the healthcare provider.
2. Review the data and modify the plan.
3. Reformulate the nursing diagnosis to a more realistic one.
4. Request a consult for the client to be seen by a pulmonologist.


2
Rationale 1: Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client physiologic responses may be.
Rationale 2: The plan of care should be evaluated periodically, at the established time frames, to determine achievement of the goals. If goals are not achieved, then the data need to be further assessed and the plan modified.
Rationale 3: Reformulating the nursing diagnosis to a more realistic one is not the best course of action as the diagnosis established came from subjective and objective data specific to that diagnosis.
Rationale 4: There are no data to support the need for additional medical consultations.

Nursing

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A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident's pain would be most suggestive of angina as the cause?

A) The pain is worse when the resident inhales deeply. B) The pain occurs immediately following physical exertion. C) The pain is worse when the resident coughs. D) The pain is most severe when the resident moves his upper body.

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A patient is being monitored by continuous ECG after placement of a transvenous pacemaker. "Loss of capture"  is seen on the ECG. Which nursing intervention may correct this situation?

a. Position the patient on the left side. b. Decrease the milliamperes as ordered. c. Increase the rate as ordered. d. Monitor the patient in a different lead.

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Which of the following patients would benefit the most from telemonitoring technology?

a. Frail 81-year-old female who lives alone b. 43-year-old female with arthritis c. 52-year-old male with prostatitis d. 67-year-old female with a thyroid disorder

Nursing

What is the office of the Department of Health and Human Services that is charged with overseeing nationwide efforts to implement and use health IT and electronic exchange of health information?

A. MARCA B. The Institute of Medicine (IOM) C. The Office of the National Coordinator (ONC) D. The American Medical Informatics Association (AMIA)

Nursing