The client at risk for acute respiratory distress syndrome (ARDS) has become cyanotic and is diaphoretic. What assessment technique should the nurse perform next?
A. Measure pulse oximetry.
B. Auscultate breath sounds bilaterally.
C. Measure the blood pressure in both arms.
D. Compare current ECG tracing with baseline measurement.
A
In early ARDS, hypoxemia may be the only abnormal assessment finding and can be life threat-ening.
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During a seminar with parents of adopted children the nurse explains that families pass through predictive stages. Upon which theory is the nurse basing this explanation?
1. Symbolic interaction. 2. Systems models. 3. Family lifecycle models. 4. Nuclear models.
The patient who has had an above-the-knee amputation refuses to look at the stump. When the nurse attempts to speak with the patient about his surgery, he says that he doesn't wish to discuss it
He also refuses to let his family visit. The nursing diagnosis that best describes the patient's problem is: A) Hopelessness B) Powerlessness C) Disturbed body image D) Fear
Tears flow over the cornea and drain via the lacrimal sac into the:
a. anterior fossa. b. posterior pharynx. c. nasal meatus. d. thyroglossal duct.
When a newly admitted patient informs the nurse that he averages 6 hours of sleep per night, the nurse determines that this patient is most likely
A) In need of sleeping pills B) Sleep deprived C) Getting efficient sleep D) In need of a sleep clinic visit