The nurse is planning daily care for two clients. One client needs postoperative teaching. The other client, who has been diagnosed with pneumonia, has a PaCO2 of 85. The nurse decides to assess the client with pneumonia first because:
1. The client needs more care than the client needing postoperative teaching.
2. The nurse can delegate postoperative teaching to an unlicensed assistive person (UAP).
3. The client with pneumonia may be experiencing respiratory distress.
4. The room of the client with pneumonia is closer than that of the client needing postoperative teaching.
3. The client with pneumonia may be experiencing respiratory distress.
Rationale:
The client with a PaCO2 of 85 could be in serious trouble. The nurse would decide to assess that client first in order to prevent dire consequences for the client. The client with pneumonia probably needs more care than the other client, but the reason for the decision is based on a potentially critical need by the client with pneumonia. The nurse cannot delegate discharge teaching to a UAP; even if delegation were permitted, the nurse would see the client with a high PaCO2 as being the greater priority. Placement of the client's room can be a decision that is made when considering time management issues; however, the physiological needs of the clients are the first consideration of the nurse.
You might also like to view...
An older adult who presents with complaints of insomnia, loss of energy, impaired concentration and diminished pleasure in activities she once enjoyed is showing signs of:
a. delirium b. dementia c. depression d. confusion
A patient is suspected of having a musculoskeletal disorder. The nurse is performing a nursing assessment on this patient. What does the nursing assessment focus on with a patient who has a musculoskeletal disorder?
A) Range of motion B) ADLs C) Gait D) Strength
The nurse is aware that the basic drive behind the patient's anorexia nervosa is to:
a. be sexually desirable by staying slender. b. be involved with preparation of food, but not eating it. c. punish self by denial of adequate nutri-tion. d. gain a sense of control by limiting food intake.
The nurse is caring for a patient with a head injury involving cerebral edema and increased intracranial pressure (IICP). To prevent further transient increases from occurring, the nurse should implement what intervention?
A. Initiate and monitor an IV with normal saline. B. Initiate oxygen administration. C. Implement measures to help the patient avoid coughing and straining. D. Position the patient in the supine position with the head of the bed at 30 degrees.