What will the nurse expect to assess in a patient with respiratory failure and hypoxemia?
1. Exertional dyspnea, circumoral cyanosis, distal cyanosis
2. Subcutaneous emphysema, absent breath sounds, sharp chest pain
3. Agitation, disorientation, lethargy, chest pain
4. Rales, distended neck veins, orthostatic hypotension
3
Rationale 1: This would not be assessed in a patient with respiratory failure and hypoxemia.
Rationale 2: These are not symptoms of respiratory failure and hypoxemia.
Rationale 3: Due to the hypoxia, the brain receives diminished oxygen and personality, perception, and the levels of consciousness are altered. Decreased respiratory reserves lead to hypoxia of the heart, which also requires higher percentages of oxygen to function. The anginal pain is a result of cardiac hypoxia.
Rationale 4: These are not symptoms of respiratory failure and hypoxemia.
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When measuring the head circumference of an infant, the nurse should place the tape measure:
a. across the eyebrows and around the occipital lobe. b. over the zygomatic arches and around the parietal areas. c. around forehead and around the crown of the head. d. above the eyebrows and pinnas and around the occipital lobe.
A healthcare organization is reviewing post-disaster feedback to improve the design and implementation of a better continuity plan for use. What is the purpose of this analysis?
A) Feedback collected is used to identify what worked and what did not because plans that looked good before a disaster may not look so good after one. B) Feedback collected after disasters (or mock disasters) is not useful because the staff had no other options during the disaster. C) Feedback collected after disasters (or mock disasters) is not necessarily accurate. D) Feedback collected after disasters (or mock disasters) provides data for change in a limited number of areas.
A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?
a. A patient who is afebrile b. A patient who is diaphoretic c. A patient with strong pedal pulses d. A patient with adequate skin turgor
During a scheduled health maintenance visit for a 6-month-old infant the nurse asks, "Does the baby sit without assistance, and is the baby crawling?" Which process is the nurse using in this interaction?
1. Health promotion 2. Developmental surveillance 3. Health maintenance 4. Disease surveillance