The nurse is assessing the client who is on a mechanical ventilator. A priority assessment for this client is:
1. assessing pedal pulses.
2. providing dehumidified oxygen.
3. using hand signals to communicate with the client.
4. ensuring that the endotracheal tube is secured.
Answer: 4
1. Pedal pulses are a priority for the client who has peripheral vascular disease.
2. When on a ventilator, the client is placed on humidified oxygen to help thin secretions.
3. Using hand signals is communication and implementation, not assessment.
4. It is critical for the client who needs mechanical ventilation that the endotracheal tube is secure, and the nurse assesses this frequently as a priority.
You might also like to view...
The nursing student is planning to study with a group of other students. Which of the following is an advantage of studying with another person or group?
1. Asking questions of each other 2. Discussing and processing ideas 3. Preparing for class 4. Meeting deadlines
A new client asks the nurse "So what goes on at this community meeting scheduled this afternoon?"
The best reply by the nurse would be a. "You and your therapist will discuss problems and goals for problem resolution.". b. "You and a small group of other clients will meet to discuss common issues.". c. "You, the staff, and the other clients will meet to discuss problems occurring on the unit.". d. "We never know what will go on at a community meeting because clients determine the agenda.".
During the admission of a patient scheduled for amputation, the patient relates that she is a practicing Orthodox Jew. The nurse should make arrangements for:
1. a veil to cover the amputated part. 2. a rabbi present for the surgery. 3. the amputated part to be buried. 4. a family member present to read the Torah.
Specimens should be transported to the lab in
A) a plastic bag with a biohazard label. B) a paper bag with a biohazard label. C) the original specimen collection container. D) a latex glove with a biohazard label.