The nurse caring for a client requiring mechanical ventilation. Which action by the nurse would be inappropriate when providing care to this client?
1. Confirming airway placement by auscultating the lungs and checking the length marking of the tube at the lip
2. Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible air leak
3. Assuring ventilator tubing is secured and does not pull on the client's airway
4. Verifying correct ventilator settings
2
Rationale 1: Airway placement should be confirmed.
Rationale 2: Tube cuff inflation should remain at 20 cm H2O.
Rationale 3: Ventilator tubing should be secure and not pull on the airway.
Rationale 4: Ventilator settings should be verified.
Global Rationale: Tube cuff inflation should remain at 20 cm H2O. Airway placement should be confirmed. Ventilator tubing should be secure and not pull on the airway. Ventilator settings should be verified.
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A nurse obtains a client's health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client?
a. "I drink two glasses of red wine each week." b. "I take a lot of Tylenol for my arthritis pain." c. "I have a cousin who died of liver cancer." d. "I got a hepatitis vaccine before traveling."
The nurse explains that the signs and symptoms caused by cancer are a result of what?
A) Overgrowth of tumor cells B) Enzymes that generate blood vessels C) Tumor cells invading healthy tissue D) Metastasis
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A) "This is the result of the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), hormones to start your period." B) "This is the result of estrogen release preparing your body to release an ovum." C) "These are the effects of progesterone, a hormone released to thicken your uterine lining." D) "This is the result of the secretory endometrium release preparing the body for pregnancy."
After an assessment, the nurse determines that the diagnosis of Constipation is appropriate for an older patient recovering from surgery. What would be a goal for this nursing diagnosis?
1. Decrease the frequency of pain medication. 2. Know the importance of hydration and activity in regard to constipation. 3. Drink at least 1,500 ml of noncaffeinated and nonalcoholic beverages each day. 4. Evacuate a formed bowel movement at least every 2 days with minimal distress.