The Air I breathe
A pt with COPD receives 2 L NC, the patient reports difficulty breathing. What is the nurse's next action?
What is assess pt's respiratory status
Assessment, Diagnosis, Planning, Implementation, and Evaluation.
What are the steps of the nursing process?
This is the most important thing you need to be aware of to reduce in prevention of a pressure injury.
What is the relief of pressure?
A nurse is auscultating heart sounds placing the stethoscope at the 2nd right intercostal space. This is the sound s/he will hear.
What is the aortic valve?
True or False: Less than 30ml/hr for urine output for more than 2 hours is cause for concern.
True!
The patient self-extubates his endotracheal tube. This is next action the nurse should take first.
What is assess the pt's respiratory status
A nurse determines that the patient’s condition has improved and has met the expected outcomes.
What is evaluation?
The nursing assessment that would indicate a wound healed by secondary intention.
What is scarring.
A patient's peripheral leg circulation indicates poor venous return to the heart. This is what is showing.
What is edema?
This is the biggest concern for a patient with an indwelling urinary catheter?
What is infection
What is high Fowlers?
The nurse checked the client's MAR and noted the last dose of pain Q4 prn medication was 6 hr. ago. She gives the pt 4 mg of Morphine. This step was left out.
What is assessment?
A client is 4 days hours post-op following abdominal surgery. An incisional wound infection is suspected. These are the findings the nurse would anticipate.
What are incisional pain, fever/chills, purulent drainage, and reddened wound edges?
This is the surface of the hand a nurse should you to palpate for skin temperature.
What is dorsal surface?
The nurse has three patients, which patient would be the priority?
-the patient with an acute asthma attack
-the patient with a foley catheter that needs assistance to ambulate to the restroom
-the patient that needs discharge teaching
What is acute asthma attack.
These are considered normal breath sounds.
What is bronchial, bronchovesicular, and vesicular
Data that you can measure or visualize with your eyes.
This is the most critical nutritional element needed for wound healing.
What is protein?
These are techniques that help the nurse obtain patient data and establish rapport.
What is empathy, friendly conversational tone, and asking for information about previous illnesses.
This is the correct placement of a foley urinary catheter when a patient is in bed.
What is below the bladder, and placed on a non-mobile location on the bed.
What is reassess.
A staff nurse delegates care to the NAP, knowing that the NAP has never performed this task. As a result the patient is harmed, and the nurse states the NAP should have known this was not appropriate. What element in the decision making process is the nurse lacking?
What is Accountability.
The nurse is assessing the abdomen. The nurse notes an abdominal wound, with slight erythema and no drainage. What part of the abdominal assessment does the nurse perform next?
What is auscultate all 4 abdominal quadrants
Breath sounds heard over the trachea
What are bronchial sounds?
What is right task/person/direction/supervision/circumstances.