The client has a nursing diagnosis of Impaired gas exchange as a result of excess secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus on the client's:
a. Ability to perform incentive spirometry
b. Lungs clearing bilaterally on auscultation
c. Complaint of chest pain
d. Respiratory rate
B
Auscultating lung sounds is the best way to determine whether airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement.
The client's ability to perform incentive spirometry does not determine whether the client's air-ways are clear. It is an intervention that may help achieve clear airways.
A complaint of chest pain would be a negative outcome, and is not the focus for determining whether airways are free of secretions, as written in the outcome statement.
Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine whether airways are free of secretions.
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The nurse is preparing to administer an antibiotic to a patient with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE)
The nurse would expect the health care provider (HCP) to order which of the following antibiotics? a. Daptomycin (Cubicin) b. Levofloxacin (Levaquin) c. TMP/SMZ (Bactrim) d. Ciprofloxacin (Cipro)
The nurse instructs a client to make a follow-up appointment with the healthcare provider 45 days after completing a prescription of antibiotics. How many months will it be until the client sees the healthcare provider?
1. 0.5 2. 1.3 3. 1.5 4. 2.2
The nurse is contributing to a group of patients care plans. Which patient should the nurse identify as being at risk for developing serum sickness?
a. A patient who receives intravenous (IV) penicillin for an infection b. A patient who has a transfusion with packed red blood cells (RBCs) c. A patient who is given cryoprecipitate and factor IX after an abdominal injury d. A patient given steroids and immunosuppressant therapy after organ transplantation