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 D
Explanation
Patient-centered care involves actively involving the patient in their care and considering their preferences, values, and goals. By discussing dietary preferences with the client, the nurse is demonstrating a patient-centered approach. This documentation indicates that the nurse took the time to engage in a conversation with the client to understand their dietary preferences,
which can help tailor the care plan to meet the client's individual needs and preferences. "Steady gait observed when ambulating" focuses on the nurse's observation and assessment but does not specifically involve the patient's preferences or goals.
"Social worker paged for consultation" indicates collaboration with another healthcare professional but does not necessarily reflect the patient's active involvement or preferences. "Nursing literature reviewed for best practice approaches" highlights evidence-based practice but does not directly involve the patient's preferences or engagement in decision-making.
Correct Answer is C
Explanation
0.9% Sodium chloride is a balanced isotonic solution that closely resembles the electrolyte composition of the extracellular fluid. It is commonly used to treat dehydration because it helps restore fluid volume and electrolyte balance in the body.
5% dextrose in Lactated Ringers: This solution is typically used for fluid and electrolyte replacement in patients who have significant fluid losses or imbalances, but it may not be the best choice for dehydration alone.
0.45% sodium chloride: This solution, also known as half-normal saline, has a lower concentration of sodium chloride and is often used for patients who require hypotonic fluids. It may not provide enough electrolyte replacement for a dehydrated patient. 3% Normal Saline: This solution has a higher concentration of sodium chloride and is typically used for specific indications, such as severe hyponatremia or in critical care settings. It is not the first-line choice for treating dehydration.
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