The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action?
a. Sedate the client.
b. Call the health care provider.
c. Assess the client for pain.
d. Assess the client's oxygenation.
D
Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the adequacy of ventilation has the highest priority. The nurse would not sedate the client until the cause of the restlessness has been addressed. The nurse would call the provider if the cause could not be determined and addressed, or if the client's status deteriorated.
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The community health nurse is making a presentation on carbon monoxide (CO) poisoning at the neighborhood health fair. Which of the following will the nurse include in her presentation? Select all that apply
a. Carbon monoxide is a colorless, odorless, and tasteless gas. b. Home-installed carbon dioxide detectors are shown to be ineffective. c. Carbon monoxide poisoning causes many older adult deaths in cold weather months. d. During rainy weather, a home fireplace with charcoal may be used for barbequing.
The nurse prepares to assess a client's point of maximal impulse (PMI). Which location should the nurse assess?
A. Second intercostal space, right sternal boarder. B. Fourth intercostal space, left sternal boarder. C. Second intercostal space, left sternal border. D. Fifth intercostal space at the midclavicular line.
A client has recently had mitral valve replacement surgery. To prevent excess serosanguineous fluid buildup, the nurse anticipates that care will include:
1. Increased oxygen therapy 2. Frequent chest physiotherapy 3. Incentive spirometry on a regularly scheduled basis 4. Chest tube placement in the thoracic cavity
The nurse notes dental issues during the assessment of an adolescent client. Which topics will the nurse explore further to determine the cause of the issues? Select all that apply
1. Use of fluoridated water 2. Use of a mouth guard when playing physical sports 3. Anorexia nervosa 4. Bulimia nervosa 5. Use of daily vitamins