The intensive care nurse is caring for an intubated client who has severe sepsis that led to acute respiratory distress. Which nursing intervention is most appropriate during this stage of sepsis?
a. Check blood glucose levels every 4 hours.
b. Monitor intake and urinary output twice each shift.
c. Decrease ventilator rate and tidal volume.
d. Administer prescribed low-dose corticos-teroids.
D
During severe sepsis, interventions should focus on decreasing hypoxia, maintaining acid-base balance, keeping blood glucose levels as normal as possible, maintaining organ perfusion, mini-mizing adrenal insufficiency, and decreasing microemboli. Treatment should include administra-tion of low-dose corticosteroids, insulin drip with blood glucose checks every 1 to 2 hours, hourly intake and output monitoring, and an increase in ventilator rate and tidal volume.
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A client with Ménière's disease is hospitalized for severe vertigo. The nurse should plan which nursing intervention to assist in management of the vertigo and nausea?
1. Encouraging frequent ambulation in the hall 2. Administration of stool softeners 3. Bed rest in a quiet, darkened room 4. Offering frequent warm beverages containing caffeine
When planning for patient teaching, the nurse is aware that which of the following factors create(s) a barrier to learning?
a. Mild anxiety b. Pain and fatigue c. Family presence d. Patient autonomy
The nurse is teaching a 70-year-old man about his depression. Which of the following statements by the client indicates that teaching has been effective?
A) "All old people get depressed at times." B) "I'm glad I'll feel better in 2 or 3 days." C) "I never knew depression could just happen for no specific reason." D) "When I reduce the stress in my life, the depression will go away."
The nurse manager would determine that a nurse understands culturally sensitive care if which statements are made? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. "Since all of our patients have the same illnesses, I sometimes get bored." 2. "I have been helping my patient understand how to choose foods from our diet menu." 3. "I am concerned because my patient needs sterile dressing changes but has no running water at home." 4. "My patient and I worked out a way to get her medications delivered to her at home." 5. "I invited a group from my church to come and sing hymns for our patients."