The nurse assesses a client in the postanesthesia recovery unit and finds a BP of 88/50, pulse 116, and respirations of 20. What other assessment data will the nurse want to collect first?
1. Pulse oximeter reading
2. Pain assessment
3. Whether the client is nauseated
4. Urine output
Pulse oximeter reading
Rationale: With a BP of 88/50, pulse of 116, and respirations of 20, the nurse will want to check the pulse oximeter reading next to determine whether there is hypoxia. A pain assessment will help determine if the cause of tachycardia may be pain; however, the blood pressure would not typically be low. Pain, in this instance, is secondary to hypoxemia, if present. Urine output is another indicator of perfusion when the blood pressure is low, but would not be the first priority assessment. Nausea is important to assess, but respiratory status is a first priority.
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a. Health-deviation need b. Developmental need c. Universal need d. Health continuum need
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1. Documenting vital signs as "TPR." 2. Charting that the "drsg was dry and intact." 3. Transcribing a verbal order as "Carbamazepine 12 mcg/ml IV push daily." 4. Documenting "Client consistently requesting IM MS for pain well before prescribed time." 5. Charting, "Client to be ambulated q.i.d."
The nurse is caring for a client with major depression. The client tells the nurse that she "just isn't sure that life is worth living." The most appropriate nursing diagnosis for the client is:
A) Self-esteem, Low, related to depressive episode. B) Hopelessness related to symptoms of depression. C) Anxiety related to lack of energy for self-care activities. D) Thought Processes, Disturbed, related to memory loss and depression.