Brandy is a 57-year-old patient with COPD. She has been admitted to the pulmonary unit of the hospital with right lower lobe pneumonia. Diane is the nurse caring for Brandy and notes that she has a respiration of 18 with retractions
Brandy complains of dyspnea. Diane knows that this is a clinical sign of which of the following? A. Hypercapnia
B. Orthopnea
C. Hemoptysis
D. Hypoxia
D
Dyspnea is the subjective sensation of breathlessness as perceived by the patient. It is a clinical sign of hypoxia. Dyspnea is associated with symptoms such as exaggerated respiratory effort, use of the accessory muscles of respiration, nasal flaring, and marked increases in the rate and depth of respirations.
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When documenting an incident in the nurse's notes, what should the nurse include? (Select all that apply.)
a. Description of injury, including diagrams of injury placement b. Date, time, and location of incident c. Name of physician and family members notified d. Chronologic order of events of the incident e. Confirmation that an incident report was initiated
During a 14-year-old's physical examination, the nurse identifies that he plays soccer and football and is complaining of knee pain when he rises from a squatting position, and difficulty with weight bearing. The nurse should suspect
a. Legg-Calvé-Perthes disease b. Osteomyelitis c. Duchenne muscular dystrophy d. Osgood-Schlatter disease
The most traditional form of charting is
a. narrative charting c. problem-oriented charting b. focus charting d. charting by exception
A client is discharged to his daughter's home. He weighs 250 pounds and is immobile. The nurse should instruct the daughter on the use of a:
A) three-person lift. B) transfer with a gait belt. C) hydraulic lift. D) stand-up assist lift.