At 1830, the NAP reports the following
Vital Signs
Blood pressure 136/72 mm Hg
Heart rate 104 beats/min
Respiratory rate 24 breaths/min
Temperature 100.6° F (38.1° C)
Spo2 93%
Has M.N.'s status improved or not? Defend your response.
You need to call the physician regarding M.N.'s status. Using SBAR (Situation, Background,
Assessment, Recommendation), what would you report to the physician?
The physician orders a chest x-ray examination. Afterward, radiology calls with a report,
confirming that M.N. has atelectasis. Should this diagnosis change your plan of care for
M.N.?
If M.N. had pneumonia, what changes might the physician have made to her plan of care?
M.N.'s sister questions you, saying, "I don't understand. She came in here with a bad
gallbladder. What has happened to her lungs?" How would you respond?
Although there has been a slight decline in heart rate and temperature and a slight increase in
oxygen saturation, M.N.'s vital signs are still abnormal and reflect that she has possibly developed
atelectasis or another pulmonary complication.
Following SBAR, you would first need to identify yourself and the patient. Then you would describe
the situation, focusing on the Spo2 of 88% and describing the earlier assessment findings: 118, 24,
101° F; auscultated decreased breath sounds and crackles in the right base posteriorly; right middle
and lower lobes percussed slightly dull; without productive cough, chest pain, or any anxiety.
You state how many hours postoperative the patient is; review the interventions you performed,
including pain medications given, ambulation efforts, and the use of IS and coughing and deep
breathing; and review the current status of the patient. You would conclude your remarks with the
belief that atelectasis is present and the recommendation that a chest x-ray (CXR) examination is
needed.
No. You should continue your plans and monitor effectiveness.
If M.N. had pneumonia, you would anticipate the physician ordering blood cultures, starting
breathing treatments, and initiating antibiotic therapy.
M.N.'s sister and perhaps M.N. are concerned that something might have gone wrong with M.N.
during her hospitalization. State everything in positive terms because they need reassurance. Inform
them that M.N. was very sick when she was admitted and that her incision site is painful. Explain
that you are giving M.N. pain medication so that she will be able to cough and breathe deeply, move
around in bed, and walk so that she will not develop pneumonia. Assure them that M.N. is recovering
well from surgery. Show M.N.'s sister how to help M.N. with ambulation and coughing.
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The nurse is planning care for a client from a different culture. Which of the following should the nurse use when planning care for this client?
1. Plan care using the same approaches as any other client. 2. Communicate to the client that culture cannot be taken into consideration with care. 3. Accept cultural practices that could be negative for the client. 4. Preserve the cultural beliefs and practices of the client.
The school nurse works with a number of children who receive medication while they are at school. In order to give medication to a child at school, the nurse must have only:
a. a call from the nurse in the pediatrician's office or health care practitioner's office b. written permission from the caregivers and a health care practitioner's order c. verbal permission from the caregivers in case of herbal medicines d. a printout from the pharmacy in the case of over-the-counter medication
The nurse is planning care for an adolescent client who will be hospitalized for several weeks following a traumatic brain injury. Which interventions will enhance family-centered care for this client and family?
1. Making all ADL decisions for the adolescent and family 2. Asking the adolescent what foods to include during meal time 3. Allowing the family time to pray each day with the adolescent 4. Encouraging the adolescent's friends to visit during visiting hours 5. Leaving all questions for the healthcare provider