After receiving a hand-off report what assessment information is the most important and immediate concern for the nurse? Select all that apply.
Appointment the next day
Low oxygen saturation
Previous injection drug user and alcohol misuse
Has productive cough severe enough to keep her awake
Marital status
Fever is present.
Elevated temp. pulse, and respiratory rate
Diagnosis pneumonia
Daughter's name
Correct Answer : B,C,D,G,H
Low oxygen saturation: Low oxygen saturation indicates a potential respiratory compromise and should be addressed promptly to ensure adequate oxygenation and prevent further deterioration.
Previous injection drug user and alcohol misuse: Past injection drug use and alcohol misuse can have significant implications for the patient's health, including increased risk of infections, compromised immune function, and potential withdrawal symptoms. It is crucial for the nurse to be aware of these factors in order to provide appropriate care and support. Has productive cough severe enough to keep her awake: A severe productive cough that disrupts the patient's sleep suggests respiratory distress or possible worsening of the underlying condition. The nurse should assess the patient's respiratory status and implement interventions to alleviate the cough and improve rest.
Elevated temperature, pulse, and respiratory rate: An elevation in vital signs, including temperature, pulse, and respiratory rate, can indicate an infectious or inflammatory process. This warrants further assessment and intervention to manage the underlying condition. Diagnosis pneumonia: The diagnosis of pneumonia indicates a respiratory infection that requires close monitoring and appropriate treatment. The nurse should assess the patient's respiratory status, administer prescribed medications, and implement respiratory hygiene measures.
The following options are not immediate concerns or relevant assessment information:
Appointment the next day: While follow-up appointments are important, they do not require immediate attention upon receiving a hand-off report.
Marital status: Marital status is not typically an immediate concern for the nurse's assessment and care planning.
Daughter's name: The patient's family member's name is not an immediate concern or relevant assessment information for the nurse's immediate care.
Fever is present: While a fever is a symptom of an underlying condition, it is not the most critical concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Assisting the patient to get out of bed is a task that can be safely delegated to UAP, as long as the patient's mobility and transfer status allow for assistance without the need for specialized nursing skills. UAPs are trained to provide basic patient care, including assisting with activities of daily living, under the supervision and direction of licensed healthcare professionals.
Teaching the patient to purse lip breath requires knowledge and understanding of the technique, as well as the ability to assess the patient's response and provide feedback. This is best done by a licensed healthcare professional, such as a nurse or respiratory therapist. Auscultating breath sounds every 4 hours requires the ability to correctly use a stethoscope and interpret the findings. This task falls within the scope of practice of a nurse or respiratory therapist who has received appropriate training.
Planning patient activities to minimize exertion requires knowledge of the patient's condition, limitations, and goals. It involves assessment, evaluation, and coordination of care, which are typically performed by licensed healthcare professionals.
Correct Answer is D
Explanation
Chemotherapy is a treatment modality used to target and destroy rapidly dividing cells, including cancer cells. It works by interfering with the cell division process, which is a characteristic of cancer cells. However, it is important to note that chemotherapy drugs can also affect normal, healthy cells in the body that undergo rapid division, such as cells in the bone marrow, hair follicles, and gastrointestinal lining. This is why chemotherapy can be associated with side effects like bone marrow suppression, hair loss, and gastrointestinal disturbances. While the molecular structure of DNA can be altered by certain chemotherapeutic drugs, this explanation is not comprehensive enough to encompass the overall mechanism of action of chemotherapy.
The statement that "cancer cells are susceptible to drug toxins" is partially true, as cancer cells are generally more vulnerable to the cytotoxic effects of chemotherapy drugs compared to normal cells.
Chemotherapy aims to disrupt the division and growth of cancer cells rather than promoting their division.
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