Which assessment finding of a client requires the nurse's immediate action?
a. Being intubated for 4 days
b. Uneven breath sounds
c. Wheezing on auscultation
d. Having the endotracheal (ET) tube taped to the lower jaw
D
The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action.
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A pregnant woman lifts weights regularly with a partner. What modification to this activity should the nurse suggest?
A. Adjust the weight bench so that it is tilted, not flat. B. Do fewer repetitions by using heavier weights. C. Do not hold your breath for more than 30 seconds. D. Use free weights instead of resistance bands.
A client is admitted with the diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) following steroids therapy. Which of the following symptoms are associated with HHNKS? Select all that apply
A) High blood pressure B) Extreme thirst C) Bradycardia D) Poor skin turgor E) Acidosis F) Hypoglycemia
A patient tells a nurse, "I have psychiatric problems and am in and out of hospitals all the time. Not one of my friends or relatives has these problems." Select the nurse's best response
a. "Comparing yourself with others has no real advantages." b. "Why do you blame yourself for having a psychiatric illness?" c. "Mental illness affects 50% of the adult population in any given year." d. "It sounds like you are concerned that others don't experience the same challenges as you."
What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs