Based on this priority, what nursing interventions do you need to perform?
What will be an ideal response?
Place him in a minimum of semi-Fowler position; administer oxygen and suction as needed. Be
prepared to assist with endotracheal intubation. Monitor vital signs frequently. Assess respiratory
function by auscultation and observation of rate, rhythm, and quality; evaluate respiratory
values such as tidal volume and vital capacity. Assess swallowing to prevent aspiration; if J.B. is
experiencing dysphagia, place him on nothing by mouth (NPO) status temporarily.
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Your patient was admitted after a fall in her home. After measuring the patient's legs, you determine that her left leg is 4.5 cm shorter than her right leg. This difference most likely indicates
a. a finding within normal limits. b. a hip fracture with displacement of the proximal femur. c. dislocation of the hip. d. flexion contractures of the hip.
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?
A) Similar causes are present in both conditions. B) Hypovolemia contains only low blood volume. C) In dehydration, only extracellular is depleted. D) Both conditions result in abnormal laboratory studies.
A male college student who is overweight and unable to participate in competitive sports becomes the life of the party and starts driving a popular sports car. He is displaying:
A) Compensation B) Reaction formation C) Transference D) Identification
A community health nurse is collaborating with local community leaders to prepare a community disaster plan. Which function is the nurse fulfilling?
A) Research B) Assurance C) Policy development D) Assessment