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 A
Explanation
Effective teaching for a patient with peptic ulcer disease focuses on promoting understanding and adherence to the treatment plan, as well as addressing lifestyle modifications that can help manage the condition. Stress reduction is an important aspect of ulcer management, as stress
can exacerbate symptoms and delay healing. If the patient acknowledges learning relaxation strategies that decrease their stress, it indicates that they have grasped the concept and are likely to implement it in their daily life.
It is crucial for the patient to understand that any potential side effects should be reported to the healthcare provider, who will then determine the appropriate course of action. Abruptly stopping medications without medical guidance can have adverse consequences. While pain relief is an important goal, the treatment for peptic ulcer disease typically involves addressing the underlying cause, such as Helicobacter pylori infection or reducing stomach acid production. The patient should follow the treatment regimen as prescribed by the healthcare provider, even if they experience pain relief, to ensure proper healing and prevent ulcer recurrence.
Different antacids have different formulations and ingredients, and they may vary in terms of effectiveness and duration of action. It is important for the patient to consult with their healthcare provider or pharmacist to determine which antacid is most suitable for their specific needs.
Correct Answer is D
Explanation
To calculate the milliliters per hour (mL/hr) for the IV infusion, you divide the total volume (in milliliters) by the total time (in hours).
In this case, the total volume is 1 liter, which is equal to 1000 milliliters, and the total time is 6 hours.
So, you divide 1000 mL by 6 hours:
1000 mL / 6 hours = 166.67 mL/hr
Rounding off, the nurse will program the IV infusion device to infuse at approximately 167 mL/hr.
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