The nurse is caring for clients in the postanesthesia care unit (PACU). Which client is ready to be extubated?
a. Client with an oxygen saturation of 90%
b. Client with a respiratory rate of 14 breaths/min
c. Client who is alert and oriented
d. Client who is coughing and gagging
D
Coughing and gagging on the endotracheal (ET) tube indicates readiness for extubation; the client should be further assessed to see whether he or she meets other extubation criteria. Often these criteria include ability to raise and hold the head up and evidence of thoracic breathing. An oxygen saturation of 90% is abnormal. Respiratory rate and orientation status are not sufficient criteria for extubation.
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Which international organization develops and maintains a family of international classifications such as the International Classification of Diseases?
a. International Health Terminology Standards Development Organization (IHTSDO) b. World Health Organization (WHO) c. International Medical Informatics Association (IMIA) d. Health Level 7 (HL7)
A pregnant client was in an automobile accident, and presents to the labor suite from the Emergency Department after she presented at the ED with a deep gash on her forearm from the crash. The client was not wearing a seat belt, and was speeding
She now seems highly agitated, is pacing continuously, and is talking very rapidly. The nurse should suspect that this client has what type of psychological disorder? 1. Schizophrenia 2. Bipolar disorder, manic phase 3. Social anxiety disorder 4. Obsessive-compulsive disorder
The nurse would stress in a discharge teaching plan for a client recovering from endocarditis that to avoid further complication, the client should
a. become actively involved in social and community activities. b. drink at least 1000 ml of fluid daily to ensure adequate hydration. c. initiate a comprehensive daily exercise program. d. notify the physician when invasive dental procedures are planned.
A 22-year-old nursing student has been taking
NoDoz (caffeine) tablets for the past few weeks to "make it through" the end of the semester and exam week. She is in the university clinic today because she is "exhausted." What nursing diagnosis may be appropriate for her? a. Noncompliance b. Impaired physical mobility c. Disturbed sleep pattern d. Imbalanced nutrition: less than body requirements