Case Study Question #4: The nurse is admitting the client th…
Case Study Question #4: The nurse is admitting the client that just arrived at the ED who has the following assessment: B/P=92/50 RR=25 breaths/min. SPO2=92% Pulse=123 beats/min. Temp.=99.1F (32.2C) Respiratory: Coarse Rhonchi bi-lateral lower lobes, increased work of breathing, productive cough with copious sputum Neuro: A & O X 4, appears fatigued Pain: 6 (0-10 scale) with cough The nurse reassesses the client at the 2 hour mark and notes the following: B/P=88/48 RR=26 breaths/min. SPO2=91% Pulse=125 beats/min. Temp.=100.2F (38C) Respiratory: Coarse Rhonchi bi-lateral lower lobes, decreasing ability to cough and profound shortness of breath Neuro: Lethargy, Alert to person only Pain: moans with painful stimulus ABG: pH 7.30, CO2 50, HCO3 26, PaO2 60 Question: Which of the following priority actions should the nurse perform next? Select all that apply.
Read DetailsThe nurse is caring for the client with a left sided chest t…
The nurse is caring for the client with a left sided chest tube who is now experiencing manifestations of a tension pneumothorax. The nurse knows that a client with a chest tube is at the greatest risk for tension pneumothorax if which of the following scenarios is present?
Read DetailsCASE STUDY Questions 19-24 Prior information: The client has…
CASE STUDY Questions 19-24 Prior information: The client has been admitted with exacerbation left-sided heart failure. The following assessment was performed by the emergency room nurse. Past Medical/Surgical History: type 2 diabetes, peripheral vascular disease, hypertension, and left toe amputation Current Medications: Digoxin, Furosemide, Metformin Allergies: Penicillin Current Vital Signs: B/P 134/82 mmHg, Pulse 126, Respirations 26 and labored, Temp 37.2 C (98.9 F), SPO2 91% on room air Admission Weight: 253 pounds QUESTION 22: The client has been given the nursing priority of impaired gas exchange. Which of the following nursing interventions should be done to help the client achieve the goal of improved oxygenation?
Read DetailsThe nurse is caring for the client who is obese, immobile, a…
The nurse is caring for the client who is obese, immobile, and prefers to lay on their right side. When completing the morning assessment the nurse notes that the client has a large reddened area on their right hip and small blisters are forming. The nurse’s priority initial intervention would be which of the following?
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