OK I THOUGHT THIS WAS ON THERE BUT WHEN I RETOOK IT THIS QUESTION WASN'T ASKED???
Nurse Craig is assessing Mrs. Jordan. Which of the following actions
... [Show More] should the nurse take next?
assess skin and nail beds for hypoxia
What additional information would assist Nurse Craig in preparing to care forMrs. Jordan? List 5 additional pieces of information that should have been included in the report
1. Levofloxacin (Levaquin)-How much was given and when is the next dose?2. Agitation-The client's baseline level of orientation. Is this agitation new or getting worse? How do you know she is tired? Did she tell you that or is she sleeping on and off?
3. Probable discharge in next 24 hr-Is there a discharge order or plan?
4. Output-Amount, color and characteristic of urine.
5. IV-The type and amount of IV solution given since arrival in the emergency department.The type and rate of IV solution that is currently infusing. Location of IV site and size of catheter.
6. Vital signs-Range of vital signs, including O2 saturation.Current vital signs.
7. Blood glucose-Results of blood glucose and time obtained.
8. Social status-Any significant others that are with her. Individuals who should be contacted about hospitalization.
9. Medical history-Pre-existing conditions, allergies, and home medications and adherence.
10. Other-Normal level of activity, history of falls, and diet at home
Nurse Craig is assessing Mrs. Jordan, which of the following actions should the nurse take
apply oxygen per nasal cannula at 2 mL/min
Nurse Craig observes that Mrs. Jordan is restless and having increased diff. breathing. which of the following assessments is appropriate for Mrs. Jordan at the time
rapid focused assessment
Based on your findings from the rapid focused assessment, which of the following actions should Nurse Craig perform first?
increase oxygen to 4L/min
Nurse Craig has received a bag of medications from Mrs. Jordan's home. He reviews each of the meds. Which of the following is best action next
Request medication reconciliation with pharmacy
Nurse Craig has reviewed Mrs. Jordan's medications received at home. Nurse Craig labels the med bag and locks the meds in a cabinet. Based on events so far, which of the following best describes Mrs. Jordan's priority underlying medical condition
cardiac
Mrs. Jordan has experienced increased respiratory distress during the past 2 hr. since admin, she received 2,550 mL IV and 100 mL PO. her urinary output since admin has been 100 mL which of the following clinical manifestations indicates exacerbation of HF and should be reported to provider? SATA
A. dependent pitting edema
E. crackles in lung
The provider has just informed Mrs. Jordan that due to her cardiac condition she is not a candidate for surgery. She is tearful and has frightened look on her face. Which is an appropriate statement?
"tell me about the concerns you have"
Nurse Debbie is preparing to provide a bed bath for Mrs. Jordan who is in Buck's traction, which is appropriate action for Nurse Debbie to take
leave the traction in place
Mrs. Jordan is at risk for skin breakdown due to age, cardiac condition and her mobility that is restricted due to Buck's traction. Nurse Stephanie assesses pt for skin breakdown and based on the photo what should she classify this as
Stage 2
Which of the following should nurse debbie include in the poc for Mrs. jordan who has a fractured hip and is in Buck's traction
Monitor mrs. Jordan ability to move her toes on the affected leg
Mrs. Jordan reports that she is SOB her SaO2 is 85%, oxygen flow rate increased to 6 mL/min, nurse debbie reassesses the pt which clinical finding is early indicator of shock
restlessness
Nurse Debbie assessed Mrs. Jordan and determined that Mrs. Jordan is at risk for which type of shock
distributive shock
rationale: pt becoming septic, widespread infection that triggers a whole-body inflammatory response
Nurse Debbie is reviewing laboratory report, which ABG indicate metabolic acidosis
pH 7.28
PaCo2 35
HCO3: 20 [Show Less]