ch 5

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It has a two-way valve that allows the first third of exhaled breath to be stored in a reservoir bag, which is then inhaled again, and the rest of the exhaled air to escape into the atmosphere. This mask can provide oxygen concentrations between 40% and 70% and is used to treat patients with hypoxia, respiratory disease, cardiac disease, shock, trauma, severe blood loss and seizures.

"Is your mask causing discomfort?"

A nurse is demonstrating critical thinking when applying the nursing process to client care. Place the behaviors in the order in which they would occur from first to last based on the nursing process. Use all options.

1-Explore ideas 2-Interpret evidence 3-Detect bias 4-Predict consequences 5-Identify client's perception of results

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client?

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

What nursing organization first legitimized the use of the nursing process?

American nursing association (ANA)

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

Arrhythmia

A nurse is caring for a middle-age client who looks worried. The client reports difficulty in breathing, even when walking to the bathroom. Which breathing disorder is appropriate to describe the client's condition?

Clients with dyspnea often appear worried. Dyspnea is difficult or labored breathing (shortness of breath). Dyspnea may be the result of heavy exercise or exertion or from a health condition. Dyspnea can be perceived only be the person experiencing it and is characterized by an increased effort to breathe is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing. The client's condition cannot be termed hyperventilation, hypoventilation, or apnea. Hyperventilation and hypoventilation affect the volume of air entering and leaving the lungs. Apnea is total absence of breathing, which is life-threatening if it lasts more than 4 to 6 minutes.

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?

Contision

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

Diagnose

A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the client's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is 3 hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which type of skills?

Ethical/legal skills Reporting problems and unacceptable practices is an aspect of ethical/legal skills. Technical skills enable the safe performance of kinesthetic tasks while interpersonal skills are the manifestations of caring. Cognitive skills encompass knowledge and critical thinking.

A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:

Laceration

A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which aspect of the nurse's execution of this order demonstrates technical skill?

Starting a new, large-gauge intravenous site on the client and priming the infusion tubing. -Performing tasks that require manual dexterity is a manifestation of technical skills. -Explaining the transfusion process largely depends on interpersonal skills. -whereas understanding the theory behind blood types is indicative of cognitive skills. -Informed consent lies within the domain of legal/ethical skills.

A hospital unit has a policy that rectal temperatures may not be taken on clients who have had cardiac surgery. What rationale supports this policy?

Thermometer insertion stimulates the vagus nerve. The Valsalva maneuver is one of several simple physical actions called vagal maneuvers that act on the vagus nerve to slow your heart rate.

What is a systematic way to form and shape one's thinking?

critical thinking Critical thinking is defined as "a systematic way to form and shape one's thinking. It functions purposefully and exactingly. It is thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned." Intuitive thinking is a feeling (a sense) that doesn't use rational processes such as facts and data. Intuition comes from years of knowledge and experience that allow a nurse to understand how clients and the world works. Trial and error is a fundamental method of problem solving. It is characterized by repeated, varied attempts that are continued until success or until the agent stops trying. Interpersonal values are the kinds of human relationships that are considered important by the client or nurse.

The nurse prepares a concept map for a client who is newly diagnosed with atrial fibrillation. According to the concept map pictured above, what is the highest prioritized nursing diagnosis?

decrease cardiac output The highest prioritized nursing diagnosis is labeled #1, and that is Decreased Cardiac Output. This is according to Maslow's hierarchy of needs. Cardiac output is a physiologic need. Anxiety, Deficient Knowledge, and Risk for Fall or Bleeding can be considered safety needs, with anxiety being a concern over one's safety.

The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?

involving the client with all the steps of the process in care development

Which age group in the population is expanding most rapidly, resulting in changes in the delivery of health care?

older adults

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified:

outcome This statement is an outcome statement that focuses on the client, is realistic, and is measurable. The pain report is objective data; subjective data would include information from the client, such as reports of pain or anxiety. Nursing diagnosis is a clinical judgment about an individual, family, or community experience/response to an actual or potential health problem. Intervention would be the action to be completed based on the nursing diagnosis and intended outcome (e.g., administering a prescribed analgesic).

Critical thinking is important in making an effective nursing judgment. Which technique would be most effective for the nursing student to adopt to improve classroom success?

turn errors into learning opportunities


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