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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Respiratory acidosis is a primary acid-base imbalance that occurs when there is an excess of carbon dioxide (CO2) in the body due to impaired ventilation or inadequate removal of CO2 from the lungs. In this case, Colleen's depressed ventilation, indicated by shallow and slow respirations, can lead to inadequate elimination of CO2 from her body. The excessive CO2 levels can result in an accumulation of carbonic acid (H2CO3) in the blood, leading to an increase in acidity and a decrease in pH.
The profuse bleeding from both ears indicates a potential head injury, which can lead to decreased neurological function and impaired control over the respiratory center in the brain. This can further contribute to depressed ventilation and the development of respiratory acidosis. Metabolic acidosis, characterized by a decrease in bicarbonate (HCO3-) levels or an increase in non-carbonic acids in the blood, is not the primary acid-base imbalance in this case since the scenario does not provide information indicating a primary metabolic disorder. Respiratory alkalosis, characterized by decreased levels of CO2 in the blood, leading to increased pH and alkalinity, is not the primary acid-base imbalance in this case. The depressed ventilation and associated increase in CO2 levels indicate the opposite, respiratory acidosis. Metabolic alkalosis, characterized by an increase in bicarbonate levels or a decrease in non-carbonic acids, is not the primary acid-base imbalance in this case as the scenario does not provide information indicating a primary metabolic disorder.
Correct Answer is E
Explanation
Dependent edema refers to the accumulation of fluid in the dependent parts of the body, which are areas that are most affected by gravity when a person is in a supine or sitting position for an extended period. The sacrum, which is the triangular bone at the base of the spine, is one such dependent area. It is prone to developing edema when there is increased fluid retention in the body, as seen in the patient's weight gain.
To assess for dependent edema accurately, the nurse can gently press the skin over the sacral area with their fingers and observe the skin turgor or the return of the skin to its normal position after releasing the pressure. If there is edema, the skin may have reduced elasticity and take longer to return to its normal position (poor skin turgor).
While edema can occur in other dependent areas such as the feet, ankles, and lower legs, assessing skin turgor in these areas may not provide an accurate determination of dependent edema as they are located further away from the sacrum and may be influenced by other factors.
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