Which is the highest priority goal to set for a client with pneumonia?
a. Absence of cyanosis
b. Maintenance of SaO2 of 95%
c. Walking 20 feet three times daily
d. Absence of confusion
B
Maintenance of an SaO2 of at least 95% is a clear goal that indicates that the client has adequate oxygenation. Absence of cyanosis and the presence of confusion are assessment factors that con-tribute to evaluation of oxygen; however, they are not absolute measures. Likewise, walking three times a day does not directly address oxygenation.
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A 10-year-old patient on a children's oncology unit has had an unsuccessful bone marrow transplant. The family is distraught but remains positive in front of the child. One night the child asks the nurse about death and dying
What counseling should the nurse give to the parents? a. Avoid talking about death in front of the child. b. Change the subject if the child asks about dying. c. Allow the child to have an honest discussion about dying. d. Allow the physician to discuss this with the child.
The nurse suspects that a patient's wound is healing slowly because of poor oxygen perfusion to the tissues. Which of the following would interfere with oxygen delivery to aid in the healing of this patient's wound?
1. smoking 2. gastritis 3. alcohol consumption 4. reduced activity
A female client has been admitted to the inpatient psychiatric facility with a diagnosis of posttraumatic stress disorder after a history of violence by her boyfriend. During the initial assessment interview, which assessment would be the priority?
A) Nutritional status B) Hydration status C) Sleep patterns D) Suicide risk
Which of the following medications is used to relieve the pain of postherpetic neuralgia?
A. Menthol topical spray B. Ethyl chloride topical spray C. Lidoderm 5% transdermal patch D. None of the above