The nurse is providing care to a client who is recovering from severe respiratory acidosis and has recently been extubated. Which of the following actions by the nurse provides an optimum environment for this client?
1. Restraining the client
2. Placing the client in a side-lying position
3. Providing a calm, quiet environment
4. Administering narcotics for pain
3. Providing a calm, quiet environment
Rationale:
The client with respiratory acidosis often experiences anxiety. This client would benefit from a calm, quiet environment in order to reduce stimulation and anxiety. Restraining the client will increase levels of agitation. The client with respiratory failure would benefit most by the semi-Fowler's or Fowler's position to increase ventilation. Narcotics will depress the respirations and increase respiratory acidosis. A non-narcotic pain reliever would be considered if this client is experiencing pain.
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What does the nursing diagnosis represent?
A) Symptoms B) Signs C) Cues D) Maladaptation
A woman at 32 weeks' gestation is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will identify which of the following as a positive patient care outcome?
a. Rise in serum creatinine b. Drop in serum protein c. Resolution of thrombocytopenia d. Resolution of polycythemia