The nurse is providing care to a patient with a fractured femur who is in traction. Which nursing intervention is the highest priority for the nurse to implement?
a. Increase daily fluid intake.
b. Weigh patient each morning.
c. Teach patient to cough and deep breathe.
d. Teach patient to cover mouth when coughing.
ANS: C
A patient who is immobile is at increased risk for atelectasis and pneumonia. Encourage coughing and deep breathing to keep airways clear and prevent atelectasis. A. Fluid intake may be increased if the patient is at risk for fat emboli or renal calculi, but it is not the highest priority over oxygenation. B. Daily weights indicate fluid and nutritional status but are not the priority for this patient because there is no indication of an increased risk for dehydration, fluid overload, or malnutrition. D. Teaching the patient to cover the mouth when coughing prevents the spread of contagious disease and is not the priority for this patient.
You might also like to view...
Which of the following actions by the nurse would meet the standard of care?
1. The nurse questioned a physician about a prescription where the dose was higher than the recommended dose. 2. The nurse medicated a client who reported severe chest pain with aspirin and then called the physician to get a prescription. 3. The nurse brings a breakfast tray into the client's room and puts in on the counter away from the client who is vomiting and nauseous. 4. A nurse leaving the facility at the end of the shift witnesses a client fall. The nurse calls for help and tells the other nurse that during the next shift he or she will fill out the incident report.
A psychiatric nurse is working with a client with generalized anxiety disorder (GAD). Which phenomenon best describes the cognitive theory of GAD?
A) Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety. B) When an individual feels vulnerable in a given situation, distorted thinking results in an irrational appraisal, fostering a negative outcome. C) The elevations in cortisol that occur during the fight-or-flight response. D) Worry is a learned response to anxiety and serves to keep it within the control of the individual.
A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, the first activity that the nurse would suggest to the task force is:
A. Teaching schoolchildren about the dangers of school violence B. Looking at what other communities are doing about school violence C. Distributing fliers that identify the causes of school violence to families in the community D. Conducting a community survey to assess community perceptions regarding school violence
The autopsy of a 55-year-old revealed an enlarged liver, testicular atrophy, and mild jaundice secondary to cirrhosis. What is the most likely cause of this condition?
a. Bacterial infection b. Viral infection c. Alcoholic steatohepatitis d. Drug overdose