The priority nursing assessment for this client is airway patency. The client's report of difficulty breathing and chest tightness, along with the presence of rash and other symptoms, suggests a potential allergic reaction or anaphylaxis. In severe cases, anaphylaxis can cause airway swelling and obstruction, leading to respiratory distress and compromised breathing.
Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status
The patient's presentation of anxiety, labored respirations at a rate of 38 breaths/min, and an oxygen saturation of 90% indicates significant respiratory distress and hypoxemia. The current oxygen delivery at 6 L/min via nasal cannula is not providing sufficient oxygenation to meet the patient's needs.
After a tonsillectomy, frequent swallowing could be a sign of bleeding. Look for any signs of bleeding on the back of the throat. The other evaluation results are typical for a 3-year-old following surgery.
The nurse should modify the care plan in response to the patient's condition and wishes. It is important to respect the patient's autonomy and preferences while providing care. If the patient refuses to walk due to fear of falling, the nurse should reassess the situation and collaborate with the patient to develop a revised plan that addresses their concerns and promotes their safety.
Large-scale fluid removal from the pleural space may result in fluid shifting from the circulation into the pleural space, which may result in hypotension and tachycardia. To remedy this, the patient might need to get IV fluids.
A sterile field is established and sterile procedure is applied when providing tracheostomy care. While necessary, standard procedures like hand washing are insufficient for providing tracheostomy care. In order to prevent infection, sterile technology is needed because the presence of a tracheostomy tube gives microorganisms direct access to the lungs. The other stages are all appropriate and correct.
A collaborative nursing intervention refers to actions or activities that involve the cooperation and coordination of multiple healthcare providers to achieve desired patient outcomes. It involves working together with other members of the healthcare team, such as physicians, physical therapists, social workers, and pharmacists, to provide comprehensive and holistic care.
Assigning the fairly new nurse, with 6 months of experience and pulled from the surgical unit, to a patient who needs teaching about the use of incentive spirometry may not be the most appropriate assignment. Teaching patients about the use of incentive spirometry requires knowledge and experience in respiratory care and patient education.
A persistent bubble suggests an air leak that needs to be located. You can attach a cushioned clamp to the drainage tubing near the occlusive dressing with the doctor's approval. If the bubbling ceases, the air leak may have occurred during the insertion of the chest tube, in which case you must inform the doctor. If you apply the padded clamp and the air bubbling does not cease, there is an air leak between the clamp and the drainage system, and you must thoroughly examine the system to find the leak.
The best rationale to support involving the patient's family members in the teaching plan is that it empowers both the patient and their support system.
A continuous nursing procedure is used to try to address the needs of the patient. The nursing process is dynamic and cyclical in character rather than linear, always reacting to the health status of a patient. A patient's health may worsen or get better, necessitating changes to the care plan. The Joint Commission mandates ongoing evaluation of patient care plans.
Please select 4 correct answers
Nasal bleeding, or epistaxis, is somewhat common but seldom fatal. Digital pressure, moderate chemical cauterization, or nasal packing are the typical treatments for anterior hemorrhage. Less frequently occurring posterior bleeding is characterized by substantial, initially bilateral bleeding that might be more challenging to control.
The point where the endotracheal tube hits the incisor teeth or nares should be marked. To ensure that the tube hasn't shifted, look for this mark. If the patient is wearing an endotracheal tube, look for accidental extubation as well as tube slippage into the right mainstem bronchus.
Monitoring and documenting intake and output are skills that the nursing assistant learns during training. The nursing assistant can remind and encourage the patient to consume enough food once the nurse has explained the significance of proper nutritional intake for energy.
