Oxygenation
A COPD patient has an SpO₂ of 88% on 2L nasal cannula and is resting comfortably. The nurse’s priority action is this.
What is assess the patient before increasing oxygen?
A patient’s urine output is 20 mL/hr for 2 consecutive hours.
The nurse recognizes this as a sign of this problem.
What is inadequate renal perfusion (or possible fluid volume deficit)?
Minimum urine output per hour indicating adequate renal perfusion.
What is 30 mL/hr?
The most effective intervention to prevent pressure injuries.
What is repositioning every 2 hours?
Teaching is most effective when this domain is addressed for skill-based learning.
What is psychomotor domain?
A patient’s oxygen saturation drops from 98% to 90%.
The nurse understands that hypoxia most directly affects this organ first.
What is the brain?
A patient has crackles, edema, bounding pulse, and elevated BP. This imbalance is suspected.
What is fluid volume excess?
An older adult becomes acutely confused with new incontinence. The nurse suspects this.
What is a urinary tract infection?
A reddened sacral area that does not blanch is classified as this.
What is Stage 1 pressure injury?
A patient states, “I don’t think I can give myself injections.” The nurse should focus on improving this concept.
What is self-efficacy?
A patient is receiving oxygen via nasal cannula at 2 L/min.
The nurse understands this device delivers approximately this percentage of oxygen.
What is approximately 28% FiO₂?
ABG results: pH 7.30, PaCO₂ 52, HCO₃ 24. This acid-base imbalance is present.
What is respiratory acidosis?
A postoperative male patient reports suprapubic pain and inability to void 8 hours after surgery. The priority assessment is this.
What is bladder distention?
An immobile patient develops unilateral calf pain, warmth, and swelling. This complication is suspected
What is DVT?
The best method to evaluate patient understanding of insulin administration.
What is teach-back with return demonstration?
A patient has shallow respirations and elevated PaCO₂.
This indicates a problem with this process.
What is ventilation?
A patient’s potassium level is 6.2 mEq/L.
The nurse knows the most serious risk associated with this imbalance is this.
What is cardiac dysrhythmias?
Cloudy urine, fever, flank pain, and positive CVA tenderness suggest this.
What is pyelonephritis?
A patient on bedrest develops crackles and fever on day 3. The nurse suspects this immobility complication.
What is pneumonia?
A patient newly diagnosed with hypertension states, “I feel fine.” This Health Belief Model component is lacking.
What is perceived severity or susceptibility?
A patient 24 hours post–abdominal surgery is restless, slightly confused, and reports feeling “anxious.”
Respirations are 26/min, SpO₂ is 92% on room air, and breath sounds are diminished in the bases.
The nurse’s PRIORITY action is this.
What is apply oxygen?
A patient receiving IV fluids develops crackles, shortness of breath, and jugular vein distention.
The nurse’s priority action is this.
What is slow or stop the IV infusion and assess?
A catheterized patient’s urine output drops to 15 mL/hr for two hours. The nurse’s FIRST action.
What is assess for the foley catheter before notifying provider?
A patient becomes dizzy upon standing after 3 days of bedrest. This is caused by this condition.
What is orthostatic hypotension?
A patient with low health literacy nods during teaching but avoids questions. The nurse’s best action.
What is use plain language and ask for teach-back?