The nurse institutes oxygen therapy for the client. Which does the nurse use for a positive client outcome of airway maintenance?
1. Increased pulse rate
2. Increased restlessness
3. Complains of lethargy
4. Oxygen saturation 95%
4
4. Oxygen saturation at 95% is a positive client outcome of oxygen therapy because it indicates a PaO2 between 80 and 100 mm Hg, which is within normal limits.
1. The nurse expects the client to be alert and awake with oxygen therapy.
2 and 3. The nurse expects normal sinus rhythm, heart rate between 60-100 beats/min, and a nonrestless client, indicating adequate oxygenation. Clients can become tachycardic as a compensatory mechanism for hypoxemia; older clients exhibit restlessness as an initial indicator of hypoxemia.
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Which observation should indicate to the nurse to assess an older patient for depression?
1. Flat affect 2. Hyperactivity 3. Racing thoughts 4. Pressured speech
What statement indicates that a client needs further teaching regarding therapy with salmeterol (Serevent)?
a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in my asthma." c. "I will use the drug when I have an asth-ma attack." d. "I will be careful not to let the drug escape out of my nose and mouth."
The nurse questions which activity for the client with thrombocytopenia?
a. Application of warm compresses to bruises b. Cleaning teeth with a soft-bristled brush c. Taking acetaminophen (Tylenol) for pain d. Using stool softeners daily for constipa-tion
The nurse is assessing a client who is three days post-op from a cesarean birth. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, she most likely will be:
A. Encouraged to ambulate freely. B. Given aspirin 650 mg by mouth. C. Given methylergonovine maleate (Methergine) IM. D. Placed on bedrest.