The nurse caring for a client with septicemia plans care based on the nursing diagnosis of altered tissue perfusion. Which of the following interventions is the priority for this client?
1. Assess temperature every hour
2. Check peripheral pulses every hour
3. Monitor heart rate every hour
4. Monitor pupil reactions every hour
2. Check peripheral pulses every hour
Rationale:
The fastest and best method of checking perfusion is to monitor peripheral pulses, capillary refill, color, and temperature of distal limbs. Assessing temperature and monitoring heart rate and pupil reaction are important when assessing a client with septicemia, but pulse checks will alert the nurse immediately of decreased tissue perfusion.
You might also like to view...
Why is the information obtained from a swab culture of a wound limited?
a. A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria. b. A negative culture may not indicate infection because chronic wounds are often colonized with bacteria. c. Most wound infections are viral, so the swab culture would not be indicative of a wound infection. d. A swab culture result does not include bacterial sensitivity information necessary to provide treatment.
One practical/vocational nursing student tells another student, "I'm computer phobic! I never understand what keys I'm supposed to use to get the thing to work." The reply that shows the best understanding about NCLEX-PN examination testing is
a. "No problem! The question comes up on the screen, and you speak the letter of the correct answer aloud to the voice-activated computer." b. "You answer practice questions before the examination begins to get you used to using the computer." c. "You'll be able to ask the test proctor for help if you get mixed up." d. "If you can't get the hang of the computer, they'll let you use paper and pencil."
Which statement best describes persons with personality disorders?
a. The patient's coping skills are severely impaired by cognitive impairment. b. The patient's maladaptive behaviors involve only a single aspect of personality. c. The patient has enduring ways of relating that often provoke negative reactions. d. The patient has considerable resilience when faced with stressful life situations.
A patient is wearing a breast binder after breast reconstruction surgery. The nurse needs to assess and document the patient's:
A. abdominal girth. B. respiratory status. C. nutritional status. D. genitourinary response.