The nurse implements the following measures for a patient with rheumatic fever: turn, cough, deep breathe, elevate head of bed, instruct on use of incentive spirometry
On which parameters would the nurse assess the effectiveness of the nursing interventions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Urine output
2. Arterial blood gases
3. Potassium level
4. Lung sounds
5. Orientation
2,4,5
Rationale 1: Urine output is not a gas exchange parameter.
Rationale 2: The outcome of the nursing measures is adequate gas exchange. Arterial blood gases are evaluation parameters used when assessing gas exchange.
Rationale 3: Potassium level is not a gas exchange parameter.
Rationale 4: The outcome of the nursing measures is adequate gas exchange. Lung sounds are used as evaluation parameters when assessing gas exchange.
Rationale 5: The outcome of the nursing measures is adequate gas exchange. The patient's orientation is an evaluation parameter used when assessing gas exchange.
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