The nurse is providing care to clients on a medical-surgical unit. Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation?
Select all that apply.
A) Encouraging deep breathing exercises
B) Assisting with positioning
C) Providing suctioning
D) Prescribing bronchodilators
E) Monitoring activity intolerance
Answer: A, B, C, E
Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
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A patient has researched a medical condition on the Internet. The nurse's best response to the patient's questions and concerns is
a. "Have you verified this information with your doctor?" b. "Quality health information is not available on the web." c. "What websites did you visit to get this information?" d. "You can't really trust what you find on the Internet."
The nurse in the walk-in clinic assesses a small piece of rock embedded in the right eye of a man who was breaking up rocks with a sledge hammer. The most appropriate action by the nurse would be to:
a. flush the eye with a continuous stream of warm water. b. instill artificial tears and cover the injured eye with a dressing. c. irrigate the eye with cool water and apply a pressure dressing. d. cover both eyes with a dressing and refer to the physician.
A major disadvantage of administering medication through a feeding tube is the clogging of the tube by ________ solutions. The most important intervention to prevent this complication is to flush the tube after giving the medication.
Fill in the blank(s) with the appropriate word(s).
A 35-year-old male pt with no health problem states that he had a flu shot last year and asks if it is necessary to have it again this year. What is the best response by the nurse?
a. No, because once you get a flu shot, it lats for several years. b. Yes, because the immunity against the virus wears off, increasing your chances of getting the flu c. Yes, because the vaccine guards against a specific virus and reduces your chances of acquiring flu and is only effective for one year d. No, flu shots are only for high-risk patients and you are not considered to be high risk