Nurse admits patient to med surg unit. Resp rate of 38. Patient using chest muscles to breathe, pulse ox
of 87 on room air, pink frothy sputum. What intervention would you implement first? - O2 at 2
Liters/Min
Caring for pt. who is intubated and receiving mechanical ventilation. What action by t...
NUR 185 test 1 Hondros
Nurse admits patient to med surg unit. Resp rate of 38. Patient using chest muscles to breathe, pulse ox
of 87 on room air, pink frothy sputum. What intervention would you implement first? - ✔✔O2 at 2
Liters/Min
Caring for pt. who is intubated and receiving mechanical ventilation. What action by the nurse would
decrease the patient's incidence of developing ventilator associated pneumonia? - ✔✔Put head of bed
at 30-45 degrees.
The nurse is administering acetylcysteine (muca-mist) as nebulizer treatment to patient. Which should
the nurse have available for adverse effect on the patient? - ✔✔Suction equipment
Patient coming in with SOB and resp. rate of 32. ABG results PH 7.3 (acid), Co2-50 Bicarb-28, PO2-70
Resp. Acidosis, what orders do you anticipate carrying out? - ✔✔Apply O2 and give med-neb treatment.
You have 4 patients in a long term care facility. Which would you check first? - ✔✔COPD patient with
resp rate of 30, O2 of 87 and on 3 Liters of O2 complaining of dyspnea.
Caring for newly intubated patient getting mechanical ventilation. Pt.'s wife was not at hosp. when this
occurred. Wife appears angry and states "What have you all done to him?" What would be your
response as a nurse? - ✔✔Explain to the patient why the patient had to be intubated, continue to
update patient's wife on condition and plan of care, I'm sorry that you walked in on him like that, I
understand this must have been very frightening.
Patient has SOB, edema in legs and face and has the following labs: BUN-95 (high), Creatinine of 9.2,
Potassium of 6.0 (high). What are you going to do - ✔✔Give Kexolate, prepare the patient a central line
for dialysis. Cardiac monitoring.
Working with a UAP, what task can be delegated? - ✔✔Instill non-prescription eye drops in patient's
eyes.
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