The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?
a. The bicarbonate level (HCO3–) is 31 mEq/L.
b. The arterial oxygen saturation (SaO2) is 92%.
c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
ANS: D
All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.
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As the LPN in charge, you should a. Check the medication log to see if she can have something for agitation b. Stay with her and allow her to be angry at the situation c. Call the physician for a restraint order d. Call her family members
After receiving change-of-shift report about the following four patients, which patient should the nurse assess first?
a. A 31-year-old female with Cushing syndrome and a blood glucose level of 244 mg/dL b. A 70-year-old female taking levothyroxine (Synthroid) who has an irregular pulse of 134 c. A 53-year-old male who has Addison's disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef). d. A 22-year-old male admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L
Which statement about restraints is correct?
a. Any member of the health team can order a restraint to protect the person. b. Restraints are almost always necessary with older adults. c. Informed consent is only required when the patient has dementia. d. The manufacturer's instructions are fol-lowed.
A pediatric nurse is caring for the fourth of five children in one family. The nurse identifies that the parents need additional safety teaching when the mother mentions that:
A. a 2-year-old can safely sit in the front seat of a car. B. teenagers need to practice safe sex. C. children need to wear a helmet and safety pads when in-line skating. D. children need to learn to swim even if parents do not have a swimming pool.