Which of the following signs or symptoms in a patient with severe long-standing bronchiectasis should the nurse report immediately?
a. Fever of 100.6°F (approximately 38°C) and dyspnea
b. Copious sputum
c. Distended neck veins and dependent edema
d. Periodic episodes of harsh coughing
ANS: C
These are signs of cor pulmonale and should be reported immediately. Fever, sputum, and cough are expected in patients with bronchiectasis.
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The Total Care Method is a traditional model used to deliver nursing care with its primary focus on:
A. One nurse assuming total responsibility. B. Efficient use of staff. C. Delivery of care in all health-care settings. D. Five different clients' total care.
When providing anticipatory guidance to parents about lying during the preschool period, which of the following would the nurse emphasize?
A) "You need to determine the reason for lying before punishing the child." B) "Lying typically occurs because the child is afraid of being punished." C) "The misbehavior is usually more serious than the lying itself." D) "It is okay to become angry when dealing with the child's lying."
The nurse is caring for a patient who has had a chest tube in place for 2 days. As the nurse begins her shift assessment, she should ensure that what equipment is at the bedside? (Select all that apply.)
a. Two rubber-tipped clamps b. Plain gauze 4 ? 4 c. Sterile petroleum gauze d. Extra drainage system e. A sterile chest tube of the same size as the one inserted in the patient
Late decelerations have a gradual decrease in FHR (onset to nadir 30 seconds) and are delayed in timing with the nadir of the deceleration occurring after the peak of the contraction.
a. true b. false