The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?
a. Give the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol).
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the patient's vital signs.
ANS: C
The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.
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In a client who needs fluid replacement therapy for DKA, the nurse would evaluate the best indicator of rehydration as
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James tells you that he is confused by his Medicare Part D coverage plan. An appropriate intervention would be:
1. Order cognitive testing to determine the source of his confusion. 2. Sit down with him and explain the whole Medicare Part D process. 3. Refer him to the Medicare specialist in his insurance plan to explain the benefit to him. 4. Request his son come to the next appointment so you can explain the benefit to him.
A group of nurses are discussing a newly admitted client with schizophrenia. One of the nurses states, "I should have known, he's homeless! They should have never closed up all the state mental facilities"
Which is the most appropriate response by an informed nurse? A) "Most schizophrenics are homeless." B) "Because they don't conform well to society, they prefer the freedom of being homeless." C) "The concept of deinstitutionalization is based on firm principles; the resources just haven't been allocated to make it a success." D) "It's unfortunate his family isn't helping him. They should feel ashamed."
When developing community diagnoses, which of the following would the community health nurse do?
A) Focus primarily on deficits of the community B) Use broad statements to guide a range of interventions C) Employ a revised nursing diagnosis format D) Substitute the terms client, family, group, or aggregate for the word patient