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- A nurse is caring for a preschooler on the pediatric unit. Exhibit 1 Provider Prescriptions Day 1, 2350: Admit for observation. Obtain vital signs every 4 hr and PRN. Administer oxygen 2 L/min via nasal cannula to maintain oxygen saturation above 95%. Initiate saline lock. Administer ceftriaxone 250 mg IV every 12 hr. Administer acetaminophen oral suspension 240 mg every 4 hr PRN for temperature greater than 38° C (100.4° F). Place on regular diet and encourage oral fluids of preschooler's choice. Monitor intake and output every 8 hr. Exhibit 2 Assessment Day 2, 0030: Preschooler lying on bed, awake and alert. Breath sounds with wheezing auscultated on expiration on the right side. Nonproductive cough with no retractions or nasal flaring observed. Abdomen soft and nondistended, bowel sounds active in all four quadrants. Preschooler reports headache and pain in abdomen. Rates pain in abdomen as a 2 on a 0 to 10 FACES pain scale. Exhibit 3 Vital Signs Day 2, 0030: Temperature 38.1°…Which of the following would the nurse expect to see in client experiencing hypoventilation? increased oxygenation in the alveoli increased carbon dioxide in the bloodstream decreased hemoglobin in the bloodstream decreased carbon dioxide in the alveoliPatient B., 60 years old, was hospitalized with the diagnosis "Myocardial infarction". On examination: cold and cyanotic skin. Respiration is frequent, superficial, arterial pressure 90/60 mm Hg, pulse - 110 beats / min (normal 60-90 beats per minute). The patient is transferred to the intensive care unit. Questions: 6. Describe typical changes of gas parameters and pH in blood at this type of TPP? 7. List the signs of adaptive reactions available to the patient.
- For each of the following Patient Profiles, determine the most appropriate triage category (red, yellow, green, or black), and why. 4. amputation of left arm - talking to you, attempting to stop the bleeding - respirations : 25/min - radial pulse : present 5. impaled object, very pale and sweaty - tells you she feel sick - respirations : 27/min - radial pulse : presentFor each of the following Patient Profiles, determine the most appropriate triage category (red, yellow, green, or black), and why. patient profiles: 1. severe right leg pain - tells you his legs hurt - respirations : 26/min - radial pulse : present 2. patient pinned under large bench - moans weakly when you talk to her - respirations : 36/min - radial pulse : absent 3. chest pain, dyspnea, cardiac history - tells you shes having trouble in breathing - respirations : 18/min - radial pulse : present 4. dislocated shoulder-bleeding - tells you his shoulder hurt - respirations : 26/min - radial pulse : present 5. cyanotic -unconscious - respirations : begins breathing when you open the airway - radial pulse : presentA 60-year-old male with a known history of chronic obstructive pulmonary disease (COPD) presents to the ED with increased shortness of breath, productive cough, and wheezing. His vital signs are: BP 150/90 mmHg, HR 110 bpm, RR 26 breaths/min, SpO2 88% on room air. What is the first-line nursing management? The first-line nursing management for a COPD exacerbation is to administer ________.
- Scenario Description: Juan Ferguson 50-year-old man with long-term emphysema who has become dyspneic and has been brought to the Emergency Department by paramedics and now is admitted to your floor for admission. He arrives alert and anxious, wheezing and still dyspneic. An IV has been started. Oxygen is started. What is my client’s primary and possible secondary diagnosis? What signs and symptoms would I expect to see with primary and secondary diagnosis? What do I need to assess? What is my top three priority assessments for this client? (Airway, breathing, circulation) What is my focused assessment for this patient and any nursing interventions I may need? What are the signs/symptoms that my client may exhibit if their condition is worsening? Give one or two reasons you would want to contact the healthcare provider?For each of the following Patient Profiles, determine the most appropriate triage category (red, yellow, green, or black), and why. patient profiles: 1. soaked with blood, no obvious killer bleed - tells you he feel dizzy - respirations : 28/min - radial pulse : non-palpable 2. lower extremities under wooden debris - tells you she can't move or feel her legs - respirations : 18/min - radial pulse : present 3. patient is face down on the floor - unresponsive - respirations : open airway, not breathing - carotid pulse : weak 4. patient gurgles but can't maintain an open airway - unresponsive - respirations : gasps - radial pulse : absent 5. patient has an open head wound, bleeding controlled - unconscious - respirations : 16/min - CRT : 2what is the triage category (red, yellow, green, black) for a patient with a patient having an asthma attack, audible wheezing, and has a respiration of 28/min, and present radial pulse?
- A nurse is caring for a client who presented to the emergency department with an acute asthma exacerbation. The respiratory rate is 36 breaths/min, and a pulse oximeter is 85% on room air with accessory muscle use to breathe. The nurse placed the client on oxygen 4 liters nasal cannula. The arterial blood gas (ABG) is as follows: pH: 7.28, PaCO2: 50 mm Hg, PaO2: 75 mm Hg, and HCO3: 26 mEq/L. Which of the following treatments is the nurse's highest priority? A) Administer bronchodilators B) Administer sodium bicarbonate Administer methylprednisolone (D) Perform a chest x-rayA 67yo male is admitted to the unit with a dx of CHF. Pt states, “I get short of breath before I’m able to make it up one flight of stairs to my room.” He also reports having to take frequent breaks while doing everyday activities. During your assessment you observe his skin to be pale pink, with swelling in his hand and feet. You also notice pt leaning forward in the bed to breathe with labored breath sounds.Patient has CAD, Acute respiratory failure, stroke, and altered mental status...weakness in RUE and unable to RASS (Las; : 0-Alert and Calm respond to questions. Upon presentation CAM Score(Last) : to the ED the patient was found to have V-tach, CBGs >1000 and was intubated Vital Sign for airway protection, admitted for AHRF PLEASE HELP WITH CARE PLAN