The nurse is caring for a patient who is in skeletal traction for a femoral fracture and notes that patient assessment data include dyspnea, hypoxia, petechial rash on chest, and hypotension. Which should the nurse implement?
a. Initiate emergency treatment measures and call the healthcare provider at once.
b. Medicate the patient for severe pain and reevaluate in 30 minutes.
c. Place the patient in semi-Fowler's position and listen to bowel sounds.
d. Review the list of patient medications and ask about any coughing.
A
These patient data are consistent with clinical indicators for a pulmonary embolism; accordingly the nurse institutes emergency treatment for the patient to restore adequate oxygenation, ventila-tion, and perfusion and preserve vital organ function. If the patient is stable enough for transport, the healthcare team provides empirical treatment, including supplemental oxygen, fluid resusci-tation, and anticoagulation, before performing diagnostic tests to determine the nature of the pa-tient's problem. The patient is not complaining of pain. If chest pain occurs from the pulmonary embolus, the nurse can administer morphine sulfate intravenously to provide pain relief but not at the expense of the respiratory rate or blood pressure. Asking the patient about coughing and repositioning in a semi-Fowler's position are reasonable nursing interventions but are not a priority at this time. The most important nursing intervention is to initiate emergency care related to the symptoms of embolism.
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A child known as the neighborhood bully recently set fire to a dumpster outside a supermarket. The parents report, "This event happened after our child was suspended from school for fighting.". These behaviors are most consistent with:
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The nurse is providing care for a young adult client with exophthalmos. Which nursing diagnosis would be the most appropriate for this client?
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