The nurse is preparing a plan of care for a newly admitted client with chronic obstructive pulmonary disease (COPD). The client currently is receiving oxygen at 4 liters per nasal cannula
Her oxygen saturation is 82%, respiratory rate is 32, heart rate is 98, and blood pressure is 102/68. Which of the following is the highest-priority nursing diagnosis for this client? 1. Activity Intolerance
2. Ineffective Tissue Perfusion
3. Ineffective Airway Clearance
4. Ineffective Management of Therapeutic Regimen
2. Ineffective Tissue Perfusion
Rationale:
Ineffective tissue perfusion is a priority nursing diagnosis for a client with hypoxemia. Without the adequate perfusion of tissues with oxygen, the client will not be able to tolerate activity or manage the therapeutic regimen. The assessment findings do not state that the client has a productive cough, so ineffective airway clearance may or may not be appropriate at this time.
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The nurse is assessing a client's sensory reception and perception. The client has a history of a motor vehicle accident several years ago that resulted in a spinal cord injury
This client is at risk for altered sensory reception of which type of stimuli? 1. Visual 2. Auditory 3. Gustatory 4. Visceral
A nurse is caring for a 10-year-old boy with a nursing diagnosis of disturbed thought processes related to anxiety. What is the priority nursing intervention to help improve thought processes?
A) Adjust communication style based on child's cues. B) Provide validation of the child's thoughts and feelings. C) Perform an age-appropriate mental status examination. D) Establish a daily routine.
In her meta-analysis of 18 quantitative studies of caring actions, Swanson demonstrated that the top five caring behaviors valued by nurses included all of the following EXCEPT
A. Listens to the patient. B. Allows expression of feelings. C. Touches when comforting is needed. D. Knows how to give shots and manage equipment. E. Realizes the patient knows him- or herself best.
During the assessment of an older patient's integumentary status, the nurse notes small areas of hyperpigmentation on the patient's hands. What should the nurse consider as the cause of this finding?
A. Hyperplasia of melanocytes in sun-exposed areas B. Decreased blood perfusion of the dermis C. Redistribution of adipose tissue D. Reduced vitamin D production