1. Question: Which assessment by the nurse most likely indicates that a patient is having difficulty breathing? The assessment that most likely indicates
... [Show More] a patient is having difficulty breathing is: Use of accessory muscles: When a patient is experiencing difficulty breathing, they may use additional muscles, such as the neck, shoulder, and chest muscles, to help with their breathing effort. This is a compensatory mechanism to assist in expanding the chest and increasing airflow when the normal respiratory muscles may not be sufficient. Other potential signs of difficulty breathing may include: Increased respiratory rate (tachypnea): The patient may be breathing faster than the normal range in an attempt to increase oxygen intake. Flaring of the nostrils: The nostrils may widen with each breath, indicating an effort to get more air into the lungs. Cyanosis: The patient's lips, fingers, or nail beds may turn blue due to inadequate oxygenation of the blood. Tripod positioning: The patient may sit upright, leaning forward and using their hands to support themselves, to ease breathing. It's essential for the nurse to recognize these signs and promptly assess the patient's respiratory status to provide appropriate interventions and support. 2. Question: Which should a nurse always do when taking a rectal temperature? When taking a rectal temperature, the nurse should always follow these guidelines:
1. Use a lubricated, disposable probe cover: Ensure the thermometer probe is covered with a disposable sheath or probe cover to maintain cleanliness and prevent the spread of infection. 2. Position the patient correctly: Place the patient in a comfortable left lateral position (lying on their left side with knees bent) or a knee-chest position for infants to facilitate insertion of the thermometer. 3. Gently insert the thermometer: Insert the thermometer probe into the rectum about 1 to 1.5 inches for an adult and about 0.5 to 1 inch for an infant, following the natural curve of the rectum. Do not force the probe and stop if there is resistance. 4. Hold the thermometer securely: Hold the thermometer in place until it beeps or until you are sure it has finished reading the temperature. 5. Remove and clean the thermometer: After obtaining the reading, remove the thermometer carefully, avoiding contact with any fecal material. Dispose of the probe cover or clean the thermometer per facility protocols. 6. Document the temperature: Record the temperature, along with the time and route of measurement, in the patient's medical record. Always follow proper infection control measures, hand hygiene, and appropriate disposal of equipment to prevent cross-contamination and maintain patient safety and dignity. Rectal temperatures are typically reserved for specific situations, such as when other routes are not feasible or when accurate core body temperature measurement is essential. 3. Question: A nurse is assessing a patient’s ideal body Which significant [Show Less]