On assessment, the nurse notes that a client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action?
a. Document the findings and reassess in 1 hour.
b. Loosen any constrictive dressings on the chest.
c. Raise the head of the bed to a semi-Fowler's position.
d. Gather appropriate equipment and prepare for intubation.
D
Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation.
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A nurse is caring for a female patient who has developed atelectasis because of thick mucus secretions. The nurse is monitoring IV administration of acetylcysteine (Mucomyst) and notices that the patient's face is flushed
The appropriate nursing action would be to A) stop the administration of acetylcysteine. B) slow the administration of acetylcysteine and administer diphenhydramine if ordered. C) remove any residual drug from the patient's face. D) dilute the acetylcysteine solution.
What information should a nurse provide to a Native American patient taking herbal remedies and nutritional supplements?
a. Herbs and vitamins are not helpful. b. If herbs and vitamins are not harmful, then they will be integrated into the plan of care. c. Medical research has shown that such al-ternative remedies are a waste of money. d. In the hospital, no physician will prescribe anything other than accepted medical protocols.
The school nurse is planning a smoking-prevention program for middle school students. The strategy that is most likely to be effective in preventing middle school children from smoking is:
1. Having a local high school basketball star come talk to the students about the importance of not smoking. 2. Having the school's biology teacher demonstrate the pathophysiology of the effects of smoking tobacco on the body. 3. Developing colorful posters with catchy slogans and placing them all over the school. 4. Having a pledge campaign with prizes awarded where students sign contracts saying that they will not use tobacco products.
Mary has come to the clinic to discuss the stress she is experiencing due to failing two exams at school
Initially, she described her failures as "the worst thing that has ever happened to me" and she stated, "There is absolutely nothing I can do to pass this course now." In response to the nurse's questions the nurse finds out there are three more equally weighted exams scheduled for the course in question. The nurse working with Mary decides to use interventions to facilitate emotion-focused coping. This decision would most probably be based on which additional comment from Mary? A) "You've got to figure out something for me to do to get me out of this situation!" B) "This is a waste of time because absolutely nothing you or I can do will make it any better." C) "I overreacted; surely together we can figure out something for me to do." D) "This is the worst thing that could ever happen to me…I'm nothing but a failure."