A patient has been admitted to the medical unit because of an exacerbation of heart failure. Over the past hour, the patient has become increasingly restless, tachypneic, and short of breath, and pulse oximetry reveals SaO2 of 78%
Which of the following actions should the nurse prioritize?
A) Providing reassurance to calm the patient and slow the patient's respiratory rate
B) Protecting the patient's airway and taking measures to promote gas exchange
C) Monitoring the patient's cardiac function
D) Obtaining a complete set of vital signs
B
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The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior to surgery that "I don't think I'll be able to handle this if I get a colostomy
I wouldn't know how to manage it." There is no "next of kin" listed in the patient's record. The patient is complaining of severe surgical pain. The nurse is correct when addressing which nursing diagnosis first? a. Pain b. Alteration in body image c. Knowledge deficit d. Risk for falls
The nurse prepares education material on nutrition for a group of community members. Which tools should the nurse use when conducting this teaching? (Select all that apply.)
a. My Plate b. Dietary Reference Intakes c. Recommended Daily Allowance d. Estimated Average Requirements e. Dietary Guidelines for Americans
An aging client with severe schizophrenia takes a beta-adrenergic blocking agent (propranolol) for hypertension as well as an antipsychotic. Given the combined side effects of these drugs, what teaching should the nurse provide?
A) Make sure you concentrate on taking slow, deep, cleansing breaths. B) Watch your diet and try to engage in some regular physical activity. C) Rise slowly when you change position from lying to sitting or sitting to standing. D) Wear sunscreen and try to avoid midday sun exposure.
A nurse enters a client's room and asks about his level of pain. The client, grimacing, says "It's fine." Which communication factor is the client struggling with?
1. Territoriality 2. Environment 3. Congruence 4. Attitude