The 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, and agitated. The patient's temperature is 100° F, and his pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago
What action should the nurse take first?
a. Auscultate the patient's lungs.
b. Assess the patient's oxygen saturation.
c. Administer the mild sedative as ordered.
d. Administer an ordered analgesic for dis-comfort.
B
Outward signs of hypoxia vary in patients, but dyspnea, restlessness, and confusion are the most common signs. While blood gas analysis is the most reliable indicator, bedside assessment pulse oximetry is quick, noninvasive, and gives a snapshot of oxygen saturation. The nurse should auscultate the patient's lungs after obtaining the oxygen saturation. Medications for sedation or discomfort do not address the patient's current condition.
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The nurse is preparing to administer intravenous fluids to a patient diagnosed with hyperphosphatemia. Which of the following solutions would be the most beneficial for this patient?
1. 5% dextrose and water 2. 0.9% normal saline 3. Lactated Ringer's solute 4. 5% dextrose and 0.25% normal saline
The nurse is identifying diagnoses appropriate for a client experiencing pain. The client has had previous episodes of uncontrolled pain in the past, and is worried about the current pain pattern
Which diagnosis would be appropriate for the nurse to include for this client? 1. Anxiety. 2. Ineffective Coping. 3. Deficient Knowledge. 4. Hopelessness.
During the implementation phase of the nursing process for medication administration, which procedure is considered essential?
a. Monitor the patient's response to the drug therapy b. Following the five rights of medication administration c. Establishing measurable and realistic outcomes d. Use NANDA nursing dagnoses to plan care delivery
A 45-year-old client is admitted to the critical care unit following a serious motor vehicle accident. A nurse performing the initial assessment is aware that major complications may include: Select all that apply.
A) Bleeding B) Wounds C) Multisystem organ failure D) Sepsis E) Shock