A patient presents with chest trauma from an MVA. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the client's tongue is blue-gray
Based on the following data, what would the nurse would expect to find? a. PaO2 of 88 and PCO2 of 55
b. Absent breath sounds in all right lung fields
c. Absent breath sounds in all left lung fields
d. Diminished breath sounds in all fields
C
The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the right lung, thus causing absent breath sounds in that lung.
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Which method is most appropriate for the nurse to use when teaching a client to walk with a cane?
1. Holding the cane on the stronger side of the body and moving the cane forward, then moving the weak leg forward 2. Holding the cane on the weaker side and moving the weak leg forward, then following with the cane 3. Holding the cane on the stronger side, stepping forward with the weak leg, and then moving the cane forward as the stronger leg moves forward 4. Holding the cane on the weaker side, stepping forward with the weak leg, and then moving the cane forward as the stronger leg moves forward
Which of the following is a type of purposive sampling? Select all that apply
A) Extreme case sampling B) Maximum variation sampling C) Snowball sampling D) Typical case sampling
When the nurse notes that the ureteral catheter is no longer draining urine, the most appropriate action would be to
a. clamp the urethral catheter to promote drainage from the ureteral catheter. b. do nothing, since this is a normal occurrence in the first 24 hours. c. irrigate the ureteral catheter with 30 ml of sterile saline. d. notify the physician immediately.
When you make patient observations, use your sight and hearing, but NOT your sense of smell
True False