Keeping in mind L.J.'s health history and admitting diagnosis, what are the most important assessments you will make during your physical examination and assessment?
What is the most serious complication of DVT? and List at least eight assessment findings you should monitor closely for in the development of Pulmonary Embolism.
Cardiovascular: Obtain baseline vital signs (VS); assess heart sounds; compare perfusion of the extremities.
Venous compromise of affected leg: Assess warmth, redness, pain, edema, Homans sign, distal pulses, capillary refill, and baseline calf and thigh girth. Don't forget to compare both legs.
Lungs: Assess breath sounds; assess for dyspnea and chest pain.
Mental status: Assess for confusion, restlessness, and lethargy.
Pulmonary embolism
• Crackles
• Cough
• Tachycardia
• Restlessness
• Dyspnea and tachypnea (occur in 85% of cases)
• Sudden pleuritic chest pain (occurs in 74% of cases)
• Apprehension
• Hemoptysis
• Fever
• Nausea and vomiting
• Cyanosis
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A 97-year-old client with renal failure has been hospitalized frequently during the past year. The client expresses "not wanting to go on like this" and fears being put on a "breathing machine" as the condition worsens
Which document could the nurse suggest that the client sign to ensure his or her wishes are carried out? a. durable power of attorney for health care b. health care directive c. life-prolonging procedure declaration d. living will
The nurse working in a community hospital is caring for a client who does not seem to be responding well to the current plan of care that has been implemented by the nursing team. Which actions by the nurse are appropriate based on this data?
Select all that apply. A) Accessing research journals for evidence that would support a change in the plan of care B) Proposing a nursing research project to the manager C) Networking online with other nurses giving similar care D) Asking the doctor for a new nursing approach to care E) Trying a different approach to care against policy
The nurse clarifies that an impairment that creates a measurable diminished capacity to work is a ____________________
Fill in the blank(s) with correct word
The nurse is caring for a 90-year-old woman who is receiving peripheral parenteral nutrition (PPN). The nurse will know to assess frequently for which of the possible complications of PPN?
A) Phlebitis C) Gingivitis B) Refeeding syndrome D) Tube feeding syndrome