A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic
What action by the nurse is the priority?
a.
Administer oxygen and reassess.
b.
Auscultate the client's lung sounds.
c.
Facilitate a portable chest x-ray.
d.
Prepare to assist with intubation.
ANS: D
This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.
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As part of the general physical assessment of a patient with cardiac disease, the nurse assesses central and peripheral pulses. What is the most accurate statement about pulse assessment?
A) All pulses should be assessed bilaterally at the same time. B) A pulse that is weak and thready would be scaled +4. C) Pulsus alternans varies in intensity with every other beat. D) Absence of posterior tibial pulses is a normal variant.
What is the advantage of using classification systems such as NANDA, NIC, and NOC?
A) These classification systems clarify the nurse's role in the health care system. B) These classification systems reduce the amount of time needed in planning nursing care. C) These classification systems identify the language of nursing. D) These classification systems are consistent with nursing paradigms.
The faith community nurse who encourages participation in political activities which impact the health and well-being of the faith community is functioning as a(n):
a. Counselor b. Facilitator c. Liaison d. Advocate
The process of developing data that do not already exist through interaction with community members is called data
1. Collection 2. Gathering 3. Generation 4. Interpretation