A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?
a. A 66-year-old client with a barrel chest and clubbed fingernails
b. A 48-year-old client with an oxygen saturation level of 92% at rest
c. A 35-year-old client who has a longer expiratory phase than inspiratory phase
d. A 27-year-old client with a heart rate of 120 beats/min
ANS: D
Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.
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The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. The initial nursing action would be which of the following?
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JoJo, a 10-year-old patient in room 1232 with a right arm and leg amputation due to osteosarcoma, has been refusing help with his daily routine. JoJo is exhibiting:
1. Beneficence. 2. Justice. 3. Veracity. 4. Autonomy.