The patient who has had surgery has called the nurse to his bedside. He reports his chest feels tight. The assessment reveals the patient has a respiratory rate of 29, inspiratory wheezes, and an oxygenation saturation of 81%
When planning the room assignment, the nurse will take into consideration the fact the patient is likely considered 1. Priority 1.
2. Priority 2.
3. Priority 3.
4. Priority 4.
1
Rationale: The patient who is Priority 1 is acutely ill and needs intensive treatment and monitoring that is not provided outside of the ICU. The manifestations are consistent with pulmonary emboli. Priority 2 refers to patients needing intensive monitoring and may potentially need additional interventions. Priority 2 patients are critically ill but have little chance of recovery from their illnesses. Priority 4 patients are not appropriate for ICU admission.
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The nurse is caring for a patient with sepsis. On completing the hemodynamic assessment, the nurse notes that the patient's afterload, measured by the systemic vascular resistance, is 400 dynes/sec/cm-5. The nurse evaluates this finding to be primarily the result of which change associated with sepsis?
1. Decreased circulating volume 2. Reaction to antibiotics used to treat sepsis 3. Marked vasodilation 4. Decreased ventricular contractility
The nurse is assessing several clients. Which clients does the nurse identify as being at high risk for falls? (Select all that apply.) The client:
a. With visual impairment such as presbyopia b. Who is reluctant to use a cane while walking c. Who performs Tai Chi exercise daily d. Who wears a hearing aid and glasses e. Who has difficulty arising from a sitting position f. Who is male and over 55 years of age
What should the nurse do to ensure the validity of comparison of electrocardiograms (ECGs) taken at different times?
A. Remove electrodes after each ECG is completed. B. Place new ECG chest leads on the client before each ECG is completed. C. Position the client supine prior to each ECG. D. Ensure that electrode placement is identical for each ECG.
A 60-year-old patient comes to the clinic reporting a sudden onset of a painful rash that began the day before. The primary care NP notes a vesicular rash along a dermatome on one side of the patient's back. The patient has a low-grade fever
The NP will prescribe: a. varicella vaccine. b. acyclovir (Zovirax). c. metronidazole (Flagyl). d. amantadine (Symmetrel).