The high-pressure alarm on a mechanical ventilator is sounding. What intervention should the nurse implement immediately?
A. Verify that all ventilator tubing is connected to the endotracheal tube
B. Check for leaks in the tubing connecting the endotracheal tube to the ventilator
C. Auscultate bilaterally for breath sounds then perform endotracheal suctioning
D. Assess mental status for impact of sedation on respiratory depression
Answer: C. Auscultate bilaterally for breath sounds then perform endotracheal suctioning
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To provide a safe environment for the patient, the nurse should be diligent in:
a. keeping a light on at night to prevent falls. b. hand hygiene between patient contacts. c. regulating the temperature to avoid drafts. d. changing the bed linen to diminish microorganisms.
The nurse is caring for a client with an IV line continuously infusing solution containing dextrose and water
The client complains of a burning pain along the course of the vein, and the nurse assesses the site to find redness, warmth, and mild swelling at the site. Based on these assessment findings, which term will the nurse use when documenting these findings? 1. Phlebitis at the IV insertion site 2. IV infiltrate 3. Extravasated vesicant drug 4. Extravasation
Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool?
1. Performing a head-to-toe assessment on a new admission 2. Placing a client experiencing shortness of breath on oxygen 3. Arbitrating a complaint between roommates over the television 4. Notifying a provider of a client's allergy to an ordered medication
The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported
The client is able to tell the nurse three symptoms. The evaluation statement would be: 1. Goal met; client able to state three symptoms 2. Goal not met; client able to list three symptoms 3. Goal not met; client unable to list five symptoms 4. Goal partially met; client able to state three symptoms