A postoperative client has a temperature of 101¡ F and scattered rhonchi throughout the chest 24 hours after surgery. The nursing diagnosis is Ineffective airway clearance
Which outcome would indicate progress toward meeting the goal of effective airway clearance?
1. "Cough produced 5 mL of yellow mucus; temperature 100¡ F."
2. "Physician notified, chest x-ray taken."
3. "Client reports having had a cold the day before surgery."
4. "Client drank 750 mL of fluids in 8 hours."
ANS: 1
You might also like to view...
What is the purpose of sand paintings when diagnosing illness in the Navajo American Indian culture?
A. Determines the cause and treatment of the illness B. Ensures that appropriate payment is made by the family C. Provides an atmosphere of calm for the medicine man D. Creates symbolic representations of the client and family
A measurement tool used to articulate the nursing workload for a specified patient or group of patients over a specific period of time is called:
a. benchmarking c. staffing pattern b. skill mix d. patient classification
A patient who is cognitively impaired is demonstrating signs of being in pain. How should the nurse assess this patient's pain level?
A) Ask the patient to numerically rate the pain B) Observe the patient often over the next several hours C) Provide the patient with a visual analog scale to gauge pain D) Go through the McGill Pain Questionnaire with the patient
A safety committee in a healthcare facility provides a safe environment for the client,
staff, and visitors. What responsibilities are associated with the safety committee? A) To take action in hazardous situations B) To be prepared for emergencies C) To track injury and illness rates D) To relieve facility staff during a disaster