A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient?
a. Observe the patient for decreased activity tolerance.
b. Assume the patient is in pain and treat accordingly.
c. Provide the patient ice chips as requested.
d. Maintain the room temperature at 65? F.
ANS: A
Systemic infection, like pneumonia, causes more generalized symptoms than local infection. This type of infection can result in fever, fatigue, nausea and vomiting, and malaise; be alert for changes in the patient's level of activity and responsiveness. Nurses do not assume but assess and communicate with the patient about pain. While providing the patient with ice chips may be appropriate, it is not a priority and there is no reason for the patient to be limited to ice. Maintaining the room temperature at 65? F is too cold.
You might also like to view...
The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patient's risk for heart failure (HF)?
A) The patient takes Lasix (furosemide) 20 mg/day. B) The patient's potassium level is 4.7 mEq/L. C) The patient is an African American man. D) The patient's age is greater than 65.
A nurse emphasizes a study that focused on the amount of time children spend using various media, such as TV, video games, and computers and stated that by cutting this time by ____%, it would have a significant impact on increasing physical activity
ANS:
The nurse reassures the patient and caregiver that part of the end-of-dying process is:
a. denial. b. despair. c. anorexia. d. depression.
The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a client's room. Which of the following steps should be taken first for a puncture?
1. Complete an injury report. 2. Encourage bleeding. 3. Initiate first aid. 4. Wash the area with soap and water.