A client has moderate acidosis. Which assessment does the nurse perform first?
a. Take the client's pulse and blood pressure, and analyze the electrocardiogram (ECG) strip.
b. Assess respiratory rate and depth and work of breathing.
c. Perform assessments of musculoskeletal strength.
d. Determine whether the client is awake, alert, and oriented.
A
Priority assessments for the client with acidosis relate to the cardiovascular system. Acidosis can lead to lethal cardiac dysrhythmias.
You might also like to view...
The nurse chooses which method and concentration of oxygen administration until intubation is established in a patient who has sustained a cardiopulmonary arrest?
a. Bag-valve-mask at FiO2 of 100% b. Bag-valve-mask at FiO2 of 50% c. Mouth-to-mask ventilation with supplemental oxygen d. Non-rebreather mask at FiO2 of 100%
After describing how to assess the sinuses to a group of students, the students demonstrate understanding of the teaching when they identify which sinuses as being located in the upper jaw?
A) Frontal B) Maxillary C) Ethmoidal D) Sphenoidal
Which of these nursing diagnoses would be appropriate for a client who is experiencing moderate anxiety?
a. hopelessness c. ineffective coping b. post-trauma syndrome d. spiritual distress
When caring for a diabetic client, the nurse notes that the client learns better when he practices the self-administration of the insulin injection by himself. In which of the following learning domains does this client's learning style fall?
A) Cognitive domain B) Affective domain C) Psychomotor domain D) Interpersonal domain