A nurse is preparing to delegate task for multiple clients at the beginning of the shift. June, Vol.97, Issue 9, pg827-830, Ricard, J. Hourly checks should be made for the following: Hourly checks should be made and recorded on the patient observation chart for the following (unless otherwise directed by the treating medical team): respiratory distress  (descriptive assessment - i.e. A nurse is performing a skin assessment for a client using the Braden Scale. Due to this the following rules should be followed: Oxygen cylinders should be secured safely to avoid injury. Which of the following tools or documents should the nurse use to communicate continuity of care?

A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Do not use a trailing zero.).

A RN is reviewing the medical record of a client is postoperative. The device requires the use of a computer and printer. Which of the following actions should the nurse take first? asthma, bronchiolitis, and pneumonia) and can be managed with SpO, Oxygen therapy should be closely monitored & assessed at regular intervals, Children with cyanotic congenital heart disease normally have SpO. The child should appear clinically well. Instruct patient and SO in use of NIPPV as appropriate. Which of the following actions should the nurse take to protect client confidentiality? Which of the following actions should the nurse take? A nurse is caring for a client who has a sodium level of 125 mEq/L. For example, patients with chronic respiratory failure depend on their hypoxic drive to breathe.
Which of the following actions should the nurse take first? Examples include nasal cannula, simple face mask, Venturi mask, and non-rebreather. centre or top of ball), or dial (Perflow brand of flow meters) when setting the flow rate.

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(See Thread the IV catheter so that the hub rests at the insertion site. A nurse in a provider's office is reviewing the laboratory reports for a client who is at risk for heart disease. In preparation for the client's procedure, which of the following precautions should the nurse take?

Non-Invasive Mode – delivers gas at a comfortable level of humidity (31-36 degrees, >10mg/L). This system is useful in accurately delivering concentrations of oxygen (21 – 95%). You may be trying to access this site from a secured browser on the server. It's indicated in patients with acute hypoxemia (PaO 2 less than 60 mm Hg or SaO 2 less than 90%) and those with symptoms of chronic hypoxemia or increased cardiopulmonary workload.

Which of the following actions should the nurse take? A nurse is caring for a client who has a Clostridium difficile infection. "I will reinsert the hearing aid if I hear a whistling sound.". Which of the following actions should the nurse take? Note: MR850 Humidifier should be placed in Invasive Mode for Nasal Prongs Therapy. Which of the following examples should the nurse use as a situation that requires an incident report? (Select all that apply). Buy now.

To test, a reflex hammer should be used just below the kneecap. Which of the following actions should the nurse take? This valve has been designed to minimize the risk of excessive pressure being delivered to the infant in the event that the nasal prongs seal around the infant's nares while the mouth is closed. A nurse is carding for a client who has diarrhea due to shigella. Which of the following statements by the client indicates an understanding of the teaching? Identify the sequence the nurse should follow. Some error has occurred while processing your request. Select the appropriate size nasal prong for the patient's age and size. Which of the following actions should the nurse take to ensure that the medication and the IV solution are compatible? Listen to the audio clip of what the nurse auscultates through his stethoscope and identify the type of breath sounds he hears. The client reports a latex allergy. (Select all that apply.). Apply intermittent suction when withdrawing the catheter. They are used for patients who can breathe on their own but who aren't getting enough oxygen for any number of reasons. Arrange food on the client's tray using numbers on the face of a clock. All related equipment should be checked and maintained in good working order because loss of oxygen therapy in a hypoxic patient could be devastating. A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy utilizing a compressed oxygen system. The heart may respond to hypoxia by increasing or decreasing its rate, depending on the severity of the hypoxic insult. A nurse is planning comfort measures to decrease painful stimuli for a client who has back pain. A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. A non-rebreathing face mask has an oxygen reservoir bag and one-way valve system which prevents exhaled gases mixing with fresh gas flow. Below is an image of the RT330 pressure relief valve. Clinical observations: A nurse is caring for a client who is postoperative. Wrap monitoring cords with stockinette and tape them in place. customerservice@lww.com. As you can see, some of these devices are invasive, while others are not. A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. For patients who aren't intubated and don't require airway protection, you can choose from a variety of high or low-flow options or consider an enclosure device. A nurse is teaching a client who has a new diagnosis of diabetes mellitus about how to obtain a capillary blood specimen using a blood glucose meter. Create your account. Make sure two fingers can fit under the sleeves. In what order should the nurse take the following actions to assist the client? Administer the medication with the needle at a 45 degree angle. Oxygen (via intact upper airway) via a simple face mask at flow rates of 4LPM does not routinely require humidification.
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following actions should the nurse take? Which of the following physical assessment techniques should the nurse use? Ensure straps and tubing are away from the patient's neck to prevent risk of airway obstruction.

A nurse is caring for a client receiving fluid through a peripheral IV catheter.

(hotspot question), D (right sternal border, second intercostal space). Oxygen therapy in the home or alternate site health care facility—2007 revision & update. Others are more complex and involve assisting the patient with the actual act of breathing while also delivering supplemental oxygen. A nurse is planning care for a client who has dysphagia and is at risk for aspiration. This website uses cookies. Which of the following examples should the RN include? Therefore, humidification of nasal prong oxygen therapy is recommended. November, Vol.134, No.5, pge1474-e1502, Ramsey, K. (2012). High flow delivery systems aren't patient dependent and will provide a more stable and consistent delivery of oxygen. Inject 10 units of air into the bottle of NPH insulin. Which of the following actions should the nurse take? Which of the following responses should the nurse make? These can be non-invasive (like CPAP and bi-level CPAP) or invasive (such as a tracheostomy or endotracheal tube attached to a ventilator). "I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them.". At RCH both simple face masks (in various sizes) and tracheostomy masks are available. (Click on the audio button to listen to the clip.). Continuous pulse oximetry for 30 minutes post cessation of oxygen therapy It's also used in emergencies when a patient needs assisted ventilation but an invasive airway hasn't been established yet.

Which of the following statements by the client indicates to the nurse an understanding of teaching?

Which of the following findings should the nurse expect? At sea level, room air is composed of 20.95% oxygen, 78.09% nitrogen, 0.038% CO2, and 0.93% argon, with the remainder made up of trace gases. A nurse is teaching a client about dietary management of hypercholesterolemia. We need to document the exact medication were taking because you might be allergic to it. As with all therapies, risks and benefits need to be considered. Use all the steps.). A nurse in a community health center is teaching a group of clients about the use of aromatherapy. A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus.

A nurse is performing medication reconciliation with a client. An orange traffic light confirms the AIRVO 2 has not been cleaned and disinfected since last use, and is not safe for use on a new patient. Some people with medical conditions that affect their breathing need a higher concentration of oxygen than this, and use supplemental (extra) oxygen at home as part of their treatment. 30 mins. Which of the following task should the nurse instruct the family to perform first? All high flow systems require humidification. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. evidence table for this guideline can be viewed here.

RN is assessing a client who has an NG tube and is receiving continuous enteral feedings. A nurse is planning care for a client who is postoperative. Which of the following findings should the NR expect? diagnosis - Enrolling in a course lets you earn progress by passing quizzes and exams. This can take the form of using air pressure to make breathing easier (non-invasive), or inserting a tube into the airway and attaching it to a machine (ventilator) that will take over the act of breathing for the patient, as well as delivering oxygen (which is considered invasive). A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following statements should the nurse make to evaluate the clients ability ot measure blood glucose accurately? The nurse should identify that the use of therapeutic touch is contraindicated for which of the following patients? I will be sure to remove my hearing aid before taking a shower. Nurses have an important role in early identification of factors that can compromise oxygen delivery to the lungs and tissues in the body, and in ensuring that patients who may require supplemental oxygen therapy are assessed and managed safely and competently.


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