A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors
ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.
You might also like to view...
Following surgical debridement, a patient with third-degree burns does not bleed. What does the nurse understand about this situation?
1. The procedure will need to be repeated. 2. The patient will no longer need this procedure. 3. The patient will need to be premedicated prior to the next procedure. 4. The patient should have an escharotomy instead.
The nurse manager has identified physical-assessment skills lacking in a new registered nurse. Using goal-setting theory, which directive would be most effective in enhancing the nurse's assessment skills?
1. "Plan to study one body system each week, and demonstrate your assessment skills to me each week." 2. "Get someone to help you with your health-assessment skills by the end of the month." 3. "Read a health-assessment book and practice your skills, or else you might lose your job." 4. "You need to work on your health-assessment skills before your next employee evaluation."
The clinic nurse describes to the student nurse that ________ is excessive saliva production in pregnancy. This condition is most likely caused by increased _______ levels
Fill in the blank with the appropriate word.
The nurse is caring for a patient on a gastrointestinal unit. The nurse would be most concerned if a patient reported which of the following?
a. "My stool is soft and dark brown; I usually move my bowels twice a day." b. "Lately, I've had two or three loose, sticky black stools every day." c. "My stool has been dark green and hard to pass lately." d. "Usually I move my bowels every day and the stool is light brown."