Communication and collaboration
A nurse is caring for a 72-year-old patient who was admitted for pneumonia. During the night shift, the nurse notes that the patient, who had been alert and oriented, is now increasingly confused and disoriented to time and place. Oxygen saturation is 89% on room air, respiratory rate is 26 breaths per minute, and lung sounds reveal increased crackles bilaterally. What is the nurse's priority action?
A. Reassess the patient in 30 minutes to determine if the condition improves
B. Administer a PRN dose of acetaminophen for potential infection-related discomfort
C. Apply oxygen via nasal cannula and document the findings in the chart
D. Notify the healthcare provider immediately of the change in patient status
What is notify the healthcare provider immediately of the patient status
The most important nursing measures after a fall are..
What is assessment, notify physician, and documentation?
this term refers to the blood flow from the heart to the vital organs of the body
what is central perfusion?
This age group would be most concerning to a nurse if they had a fever?
this type of person is not typically a good fit for group work.
What is self serving?
The A in SBAR stands for?
What is Assessment
what is the SA node?
this is how aging affects thermoregulation
what is the slowing of the metabolism leading to harder time regulating temps?
this is not a reason to have a patient in restraints.
what is a fall risk?
What is the patients bedside
this precaution should be taken when a patient is having suicidal thoughts.
what is removing harmful objects
alterations in electrolytes can have this impact on perfusion.
what are Cardiac dysrhythmias?
this is a priority action when you are taking care of a patient that is wet and hypothermic.
What is taking off the patients wet clothes?
this is the typical place to get a core body temp
This type of communication is through touch and feel
What is Kinesthetic
throw rugs are considered this
what is a fall risk
These two quick assessment skills give the nurse a good indication of the perfusion status of the patient
what is vital signs and what is CRT?
What is red sweaty skin?
these are the priority assessments for patients.
This type of communication could be helpful and effective when the patient has elevated work of breathing.
What is yes or no questions?
These are important things to ensure are done correctly when you have a patient with restraints
(3 of the 5)
what is --
an order within the hour,
patient restrained in anatomical position
quick release knots
secured on non-movable place
two fingers under restraints
Smoking leads to what abnormality that decreases the efficiency of perfusion.
this age group is at an increased risk for hypothermia.
what is a premature baby?
This is how I feel about the first test in this class.
CONFIDENT