Take My Breath Away
The nurse notes that the patient has an O2 saturation of 85%. The nurse’s best first action is to
apply O2 at 2L per nasal cannula
A term used to describe our ability to think
cognition
What are we assessing when we say alert and oriented x4?
person, place, time, situation
What are some alternative treatments for pain relief?
guided imagery and relaxation, massage, ice/heat, repositioning
A nursing student is to administer/monitor oxygen at 2 liters per minute via nasal cannula for the patient. Under what area of the nursing process would this fall?
Intervention
The primary function of the alveoli
To carry out gas exchange
What questions would you ask to assess a patient's short term memory?
what did you have for supper yesterday
You are caring for a patient with macular degeneration. Where is the best place to put the TV?
In the peripheral view of the patient.
Questions to ask about pain: (PQRST)
Provoking factors, quality of the pain, region (location)/radiation, severity, time/how long have they had the pain
What assessment finding would you expect to see in a patient with iron deficiency anemia?
fatigue and activity intolerance
Assessment data indicates the patient is experiencing mild dyspnea. What is the first intervention you should do?
Assist the patient into a high fowlers position.
The nurse is caring for an adult patient with aphasia. Which nursing interventions (actions) should be included when communicating with the patient?
face the patient when speaking
speak slow and maintain eye contact
provide simple, short directions
use close-ended questions
Name some interventions for a patient experiencing sensory overload?
Reduce volume of TV/radio
Limit visitors/private room
Limit awakening patient for unnecessary tasks
The nurse notices that a patient experiencing pain and requesting medication is moody and withdrawn. The patient does not show any facial grimacing, guarding, or wincing behaviors. The patient’s blood pressure is 124/78 and the pulse is 74. What does the nurse conclude about this patient?
The absence of pain signs and symptoms could indicate the patient suffers from chronic pain
A nurse is doing discharge teaching with a client. Of the following barriers to learning that the nurse identifies, which would the nurse interpret as a need to postpone the teaching session?
a. hearing loss; b. pain 8/10; c. decreased ability to ambulate; d. different culture from the nurse
b. pain 8/10.
What nursing intervention (action) is most important to include in the plan of care for a patient with a history of smoking and risk for developing pneumonia?
Instruct patient to complete incentive spirometry 10-20 times per hour
The nurse is caring for a patient experiencing dementia from Alzheimer’s disease and is providing teaching to the patient and family. The nurse will include the following information:
Dementia is progressive and includes impairments in memory and thought processes
In assessing sensory function, what are some normal age related changes in an elderly patient?
I need more sugar on my oatmeal
I need my glasses or a magnifying glass to read the newspaper
I can't hear the birds like I used to
The patient verbalizes a pain level of 2 (0-10 scale), but exhibits extreme facial grimacing while moving in bed. What is the nurse's best action in response to this observation?
Ask the patient about the grimacing when moving.
A resource for a caregiver suffering from caregiver fatigue?
Adult day services program
The nurse is caring for a patient receiving oxygen per nasal cannula. What intervention is appropriate to meet the goal to maintain skin integrity?
Assess patient's external ears, nares, and nasal mucosa for breakdown at least once a shift
The nurse notes that the patient is confused when admitted to the hospital. A family member accompanies the patient. Which question will best help the nurse to identify the cause of the confusion as the nurse interviews the patient and family member?
Is this behavior different from what it has been lately?
Sensory deficits can lead to problems with safety. Which is a common clinical manifestation of vision and hearing deficits in the elderly?
Altered spatial perception
A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription of Vicodin 5/325 (Hydrocodone/Acetaminophen). What patient education should the nurse provide?
“You need to drink plenty of fluids and eat a diet high in fiber while taking these.”
What medication do you need on hand, if your patient is using a PCA with morphine?
Naloxone hydrochloride (Narcan)