The nurse identifies the diagnosis Potential for Ineffective Gas Exchange as appropriate for a patient with pneumonia. Which independent nursing actions should the nurse plan for this problem? (Select all that apply.)
a. Apply oxygen, 2 liters, per nasal cannula.
b. Turn and reposition in bed every 2 hours.
c. Coach to deep breathe and cough every hour.
d. Administer intramuscular antibiotic medication.
e. Encourage to drink 240 mL of fluid every 2 hours.
ANS: B, C, E
B. C. E. Independent nursing actions are those that can be implemented without an HCP's order. A. D. Interventions that need an HCP's order include administering oxygen and medication. These are collaborative interventions.
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Mr. E, an elderly man who lives alone, has hypertension and diabetes but seems to manage both conditions quite well. Three times a week he drives to a dialysis center for dialysis
He injects himself with insulin and is in charge of his medications and meals. Because Mr. E is lonely, he often has lunch or dinner in restaurants where he may eat and drink unwisely, but he takes his medicines with him. What could a nurse at the dialysis center suggest that would most help Mr. E in managing his conditions? A) Eat at home most of the time B) Take a list of approved foods to the restaurants C) Find some social activities that do not involve eating D) Test your blood pressure and blood sugar after returning home
During an assessment of the eye, the optic nerve can be evaluated by:
1. Direct ophthalmoscope examination. 2. Using dilation eyedrops. 3. Shining a pen light into the eye. 4. A tonometer.
Due to your mother's illness, you have been absent from work for 2 weeks. After receiving a nasty e-mail from your supervisor, you find yourself becoming extremely angry
What should you do before responding to the supervisor's insensitive e-mail? a. Ignore the message b. Cool off before responding to the message c. Respond immediately to the e-mail and attach a letter of resignation d. Find a lawyer to sue the supervisor for harassment
A nurse is caring for a client with terminal cancer at the client's home. Why should the nurse put greater emphasis on teaching with the family members taking care of the client?
A) Family members may have to manage the patient care controlled analgesia pump to manage the client's pain. B) Family members are expected to provide primary healthcare. C) Family members are required to understand the advanced technical levels of care. D) Hospital stays may need to be decreased.