A client who has amyotrophic lateral sclerosis (ALS) has a nursing diagnosis of Ineffective breathing patterns related to weakness of respiratory muscles and fatigue. Which goal is appropriate for this diagnosis?
a. Client will experience less fatigue.
b. Client will maintain highest functional ability within limitations of the disease.
c. Client will maintain adequate PaO2 levels.
d. Client will swallow with minimal choking and coughing, and no aspiration.
C
The nursing goal related to the weakness of respiratory muscles and fatigue should be to maintain adequate oxygenation levels as indicated by PaO2 levels.
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The nurse is caring for a patient who is hospitalized with cognitive impairment. The following interventions will assist the patient in orientation: (Select all that apply.)
a. Keep a photo of the family in the room. b. Use a clock on the wall. c. Make sure the room is kept bright and well lit. d. Avoid moving the patient from room to room. e. Have the nurse introduce himself or herself to the patient.
In order to practice as a registered nurse in British Columbia, a person must have current practicing registration with the College of Registered Nurses of British Columbia. Registration is best described as:
1) The least restrictive level of regulation, requiring qualified practitioners to register with a professional body. 2) The most restrictive level of regulation that allows only licensed individuals to perform specific interventions or care. 3) A level of regulation that is granted only to individuals who meet certain educational and practice requirements. 4) A higher level designation indicating professional competency and expertise within a specialty practice area.
The nurse is assessing a client who is 36 weeks pregnant. Her current pulse is 101 bpm, which represents an increase of 10 bpm since her first assessment at 9 weeks of gestation. Which is the nurse's best action related to this assessment finding?
A. Document the finding, because it is considered within normal limits. B. Retake the pulse in 15 minutes and ask the client to lie quietly during this time. C. Teach the client to take her pulse and to record it twice a day. D. Report the assessment finding to the healthcare provider (HCP) immediately.
Describe the proper procedure for instilling an eye ointment.
What will be an ideal response?