The nurse admits an alert client with a diagnosis of pneumonia and assesses vital signs and oxygen saturation. The client's respiratory rate is 26, and oxygen saturation is 89%
What actions can the nurse take independently to support respirations and reduce hypoxia? 1. Apply oxygen.
2. Raise the head of the bed.
3. Administer a bronchodilator.
4. Insert an oral airway.
2
Rationale: The nurse should raise the head of the bed and place the client in either the high Fowler's or orthopneic position to improve oxygenation. Administration of oxygen and bronchodilators require a physician's order, and cannot be performed independently. Inserting an oral airway would not improve oxygenation, and is contraindicated in an alert adult client who does not have an airway obstruction.
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1. Write a note to the nurse involved explaining the need for an incident report. 2. Ignore the error because it's none of the nurse's business. 3. Report the error to the nursing supervisor to deal with the incident report. 4. Complete an incident report according to facility policy.
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a. Bleeding b. Sore tongue c. Hypercalcemia d. Hypokalemia
The client has been ordered treatment with Aralen. The nurse expect to see decreased _____ in the client
a. serum glucose b. potassium c. hemoglobin and hematocrit d. calcium
Which statement by the nurse could be construed as judgmental?
A) "How often do your adult children visit?" B) "Your husband's death must have been difficult for you." C) "You must quit smoking because it is offensive to others." D) "How do you feel about getting older?"