The nurse is documenting care for a ventilated client. Which items are appropriate for the nurse to include in the documentation?
1. Assignment of suctioning to the unlicensed assistive personnel (UAP)
2. Client response to ventilator changes
3. Pertinent laboratory values, such as arterial blood gas results
4. Physical assessment findings
5. Pain rating using an appropriate pain rating scale
2, 3, 4, 5
Rationale 1: It is not appropriate for the UAP to suction an intubated client requiring mechanical ventilation.
Rationale 2: When providing care to a ventilated client, the nurse will document the client's response to ventilator changes.
Rationale 3: When providing care to a ventilated client, the nurse will document laboratory data such as arterial blood gas results.
Rationale 4: When providing care to a ventilated client, the nurse will document physical assessment data.
Rationale 5: When providing care to a ventilated client, the nurse will document pain level.
Global Rationale: When providing care to a ventilated client, the nurse will document response to ventilator changes, laboratory data such as arterial blood gas results, physical assessment data, and pain level. It is not appropriate for the UAP to suction an intubated client requiring mechanical ventilation.
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The nurse is assessing a family to determine if they have access to adequate health care. Which of the following statements accurately describes how certain families are affected by common barriers to health care?
A) After a decade of escalation, the percentage of children living in low-income families has been on the decline since 2000. B) White, non-Hispanic children overall are more likely than African American and Hispanic children to be in very good or excellent health. C) The proportion of children between the ages of 6 and 18 who are overweight is decreasing, but a large increase is occurring in African American females. D) The overall health care plan of working families may improve access to specialty care but limit access to preventive services.
The 5-year-old has recurrent night terrors. What nursing intervention would the nurse plan to help alleviate this problem?
A) The next morning, ask the child to describe the event. B) Have the child walk around in the room when night terrors occur. C) Use an additional pillow behind the child's head at night. D) Have the child empty the bladder prior to going to bed.
The client reports participating in water aerobics for 60 minutes three times each week. This is an example of what type of outcome?
A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome
A client has an enlarged scar as a result of abdominal surgery. The nurse realizes this scar would be considered a(n):
1. erosion. 2. fissure. 3. excoriation. 4. keloid.