The nurse is caring for a client admitted with pneumonia requiring oxygen administration. Which are the priority assessments to document for this client?
1. Pulses in all extremities
2. Respirations and oxygen saturation
3. Blood pressure and temperature
4. Pulse rate and blood pressure
Correct Answer: 2
The priority assessments to document for this client will be respiratory status and oxygen saturation, as the plan of care will focus on the need for respiratory treatment and support. Complete vital signs should be measured often, but the priority is respiratory status.
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The nurse is planning discharge education for a client who had an exploratory laparotomy. Which nursing statement is appropriate when teaching the client to monitor for early signs of shock?
a. "Monitor how much urine you void and report a decrease in the amount." b. "Take your temperature daily and report any below-normal body temperatures." c. "Assess your radial pulse every day and report an irregular rhythm." d. "Monitor your bowel movements and re-port ongoing constipation or diarrhea."
Which fluid or product to be infused requires a central venous access rather than a peripheral access?
A. Fresh-frozen plasma B. Parenteral nutrition formula C. Dextrose 10% in water (D10W) D. 0.9% sodium chloride (normal saline)
The pediatric nurse caring for a child with increased intracranial pressure knows that priority nursing interventions include:
Select all answers that apply. A) preventing hyperthermia. B) lowering the head of the bed. C) maintaining a patent airway. D) administering mannitol (Osmitrol).
The nurse is providing developmentally appropriate care for a toddler hospitalized for observation following a fall down the steps. Which measures might the nurse consider when caring for this child? Select all that apply
A) Use the en face position when holding the toddler. B) Use a bed for toddlers who have an adult present. C) Avoid leaving small objects that can be swallowed in the bed. D) Explain activities in concrete, simple terms. E) Allow the child to select meals and activities. F) Encourage parents to stay to prevent separation anxiety.