Which of the following nursing goals is a priority when caring for the awake and oriented head injured patient?
A) Maintaining caloric intake
B) Demonstrating normal sleep-wake cycles
C) Keeping blood gas values within normal range
D) Maintaining intact skin integrity
Ans: C
Feedback: The brain is extremely sensitive to hypoxia, and a neurologic deficit can worsen if the patient is hypoxemic. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.
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How do computers and nursing informatics improve patient care? (Select all that apply.)
1. Learning more about best practices 2. Acting as a monitor to protect patient safety 3. Providing easy access to new knowledge 4. Delivering hands-on care 5. Using critical thinking to plan care
The nurse counsels the immobilized patient that to prevent muscle atrophy and contractures, the patient must have:
a. additional calcium. b. additional protein. c. some type of exercise. d. a special protective bed.
When administering intravenous (IV) fluids, the nurse ensures that the IV fluids are infusing as ordered to prevent dehydration in an adult. Dehydration can become lethal if the patient loses:
a. 5% of body fluid. b. 10% of body fluid. c. 15% of body fluid. d. 20% of body fluid.
A client has septic arthritis of the knee and the inflammation is beginning to subside. The best nursing action to prevent joint contractures at this point is to
a. encourage the client to get out of bed and ambulate. b. have physical therapy plan an active ROM regimen. c. immobilize the joint in a sling until the infection resolves. d. provide passive ROM for the affected joint.