Which information obtained by assessment ensures that the client's respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client's oxygen saturation is 97%.
D. The client's chest movements are uninhibited
C
Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effective-ness is the maintenance of oxygen saturation within the normal range.
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The nurse recognized which of the following as symptoms of wet age-related macular degenera-tion (AMD)? (Select all that apply.)
a. Rarely causes severe visual impairment b. Yellow deposits under the retina c. Decrease in central vision d. Visual distortion
An ancillary staff member new to the night shift states, “I love working, but lately I’m so depressed for no apparent reason. What should I do?” Which nursing response would be most therapeutic?
a. "I'm sure it is just temporary. If you just visit a tanning salon, the depression will be relieved more quickly.".
b. "As your friend I cannot advise you. You need to see a psychiatrist. Remember, the longer you wait, the worse depression becomes.".
c. "It may be that you aren't getting enough sunlight working the night shift. I'd suggest you discuss the possibility of phototherapy with your health care provider.".
d. "This seems temporary and will most likely disappear when you get used to this work schedule. In the meanwhile, get one of those special lights for your home.".
The community has a large number of immigrants. The nurse organizes a home visiting program to this community area to address family health concerns and provide health information. This is considered:
1. Care of the sick. 2. Case finding and referral. 3. Health promotion and illness prevention. 4. Health protection.
A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia?
a. Client with heart failure using a salt subs-titute b. Client taking a thiazide diuretic for hypertension c. Client taking nonsteroidal an-ti-inflammatory drugs daily d. Client with type 2 diabetes taking an oral antidiabetic agent