The patient who received a first dose of an opioid drug is not arousable and has an oxygen saturation of 88% (five percentage points lower than his or her normal saturation) even when fully awake. What is your best next action?
a. Wait 2 minutes and recheck respiratory rate and oxygen saturation.
b. Shake the patient firmly and keep trying to arouse him or her.
c. Notify respiratory therapy to draw an arterial blood gas.
d. Call for help and apply supplemental oxygen.
ANS: D
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A nurse is developing a plan of care for a client who was recently diagnosed with human immunodeficiency virus (HIV). The client states, "I don't plan on giving up sex just because I am HIV positive."
Based on this data, which nursing diagnosis is the priority for this client? A) Risk for Infection B) Death Anxiety C) Deficient Knowledge D) Social Isolation
Which of the following goals did the nurse write correctly?
a. The nurse will give the client a back rub to relieve pain. b. The client will have less pain. c. The client will plan a day's meals for a 1000-mg sodium diet by Friday. d. The nurse will assist the client with bathing.
During an MSE a patient says, "I am a special messenger sent to provide the world a cure for cancer." The patient's statement indicates the presence of
a. a phobia. b. a delusion. c. hypervigilance. d. loose associations.
Sandra has palpitations that are occurring with muscle twitching, paresthesia, and fatigue. What might a specific diagnostic test be to determine the cause?
a. Serum calcium b. Electrocardiogram (ECG) c. Thyroid-stimulating hormone (TSH) test d. Complete blood cell count (CBC)