A nurse is caring for a patient with left sided hemiparesis who has developed bronchitis and has a heart rate of 105, blood pressure of 156/90, and a respiration rate of 30 . Which nursing diagnosis is the priority for this patient?
a. Activity intolerance
b. Risk for skin breakdown
c. Impaired gas exchange
d. Risk for infection
C
The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity.
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The nurse has collected the following information on a patient: palpated blood pressure-180 mm Hg; auscultated blood pressure-170/100 mm Hg; apical pulse-60 beats per minute; radial pulse-70 beats per minute. What is the patient's pulse pressure?
a. 10 b. 70 c. 80 d. 100
After general anesthesia is administered, the patient is carefully placed in the prone position. What is the primary consideration of the nursing staff as the patient is positioned?
a. Making sure that the patient's endotracheal tube does not become kinked b. Ensuring that the patient's head is positioned to prevent cervical nerve injury c. Carefully taping the patient's eyes shut to avoid corneal abrasions d. Padding the operating table carefully and keeping linens free of wrinkles
A mother asks when toilet training is most appropriately initiated. What is the nurse's best response?
a. "When your child is 12 to 18 months of age." b. "When your child exhibits signs of physical and psychological readiness." c. "When your child has been walking for 9 months." d. "When your child is able to sit on the ‘potty' for 10 to 15 minutes."
A nurse is starting a position with a large agricultural farm in the Central California valley, where most of the migrant workers are recent immigrants to the area
This farm has never before employed an OEHN, and so the nurse wants to establish a training program especially for these newly immigrated workers. What information and assistance is particularly helpful for this population? Select all that apply. A. Safe work practices B. Assistance in locating shelter and food C. Financial assistance for education D. Complaint policies E. Immigration assistance