A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient?
1. The patient has ventilation failure.
2. Without treatment the patient's oxygen saturation is likely to drop rapidly.
3. The patient has decreased airflow.
4. The patient is at risk for respiratory muscle fatigue.
5. Acute respiratory failure is present.
2, 4
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When a patient asks if he can keep the heating pack on his leg all the time, the nurse reminds him of which of the following complication of long-term heat application?
a. The heat can cause extreme vasoconstriction. b. The heat can increase the possibility of infection. c. The heat can cause the blood pressure to increase. d. The heat can damage epithelial cells.
An example of monitoring outcomes in CQI would be:
A) Timeliness of medication administration B) Number of infections reported in clients with indwelling catheters C) Complaints related to room temperature D) Staffing ratios in ICU
What are important factors in setting nursing priorities? Select all that apply.
A. Patient condition B. Reassessment data C. modification of the plan of care D. feedback from the family and healthcare team
When assessing the skin surface on a pediatric, you grasp the skin of the abdomen between your thumb and index finger, pull the skin taut and quickly release, and notice 'tenting.' This is a sign of:
A) Abdominal trauma B) Dehydration C) Evisceration D) Meningitis