The nurse assesses the client receiving mechanical ventilation. Which does the nurse use to continue with the nursing plan of care?
1. PaO2 96 mm Hg
2. Sternal retractions
3. Bilateral tactile fremitus
4. Subcutaneous emphysema
1
1. The partial pressure of oxygen in arterial blood has a range of 80–100 mm Hg on room air and indicates the client's blood is more than 95% saturated with oxygen. This is an expected finding and is consistent with clinical indicators of effective gas exchange and nursing care. The nurse continues to monitor the client's respiratory status for evaluation of nursing care.
2. Sternal retractions are an unexpected finding for the client receiving mechanical ventilation because they illustrate that the client is working very hard to breathe. Sternal retractions are consistent with clinical indicators of hypoxia.
3. Tactile fremitus is consistent with clinical indicators of lung consolidation and can mean the client has an abscess or pneumonia.
4. Subcutaneous emphysema on the client receiving mechanical ventilation is consis-tent with clinical indicators of barotrauma; the nurse needs to notify the provider and obtain a chest x-ray to evaluate the client for a pneumothorax.
You might also like to view...
The student nurse asks why the nurse is documenting the client's nonverbal responses in addition to verbal responses during the initial assessment
Which of the following statements made by the nurse reflects the rationale for documenting both verbal and nonverbal responses? 1. "It is the hospital policy to document both." 2. "It is important to be thorough when documenting." 3. "Documenting both permits the reader to compare the behaviors for congruence." 4. "Charting verbal and nonverbal helps me remain objective."
The nurse is preparing to administer a medication to a 5-year-old who weighs 35 pounds. The prescribed single dose is 1 to 2 mg/kg/day. Which of the following is the appropriate dose range for this child?
A) 8 to 16 mg B) 16 to 32 mg C) 35 to 70 mg D) 70 to 140 mg
A patient who is taking the tyrosine kinase inhibitor sunitinib (Sutent) calls to report red, painful, and swollen palms and soles of feet. The nurse will perform which action?
a. Notify the patient's provider of this adverse reaction. b. Reassure the patient that these are common side effects. c. Recommend taking acetaminophen for discomfort. d. Suggest taking diphenhydramine to help with the swelling.
After a person has a subtotal gastrectomy for chronic gastritis, which type of anemia will result?
a. Iron deficiency b. Aplastic c. Folic acid d. Pernicious