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- Category: Management of Care During the endorsement, which of the following clients should the on-duty nurse assess first? A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute. B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a "do not resuscitate" order. C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin. D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem).Scenario: Upon completing a medical history and physical assessment the nurse learns that the client has an eight-year history of chronic obstructive pulmonary disease (COPD) and continues to smoke ½ pack of cigarettes daily. The client is febrile (101.20 F) and reports experiencing periods of chilling. The client has a productive cough resulting in large amounts of purulent sputum and reports, "All this coughing and difficulty breathing makes my chest hurt." The client's spouse shares that the client hasn't been eating or drinking as well as usual and constipation has been a problem for the last 3 days. Both covid-19 infection and pneumonia are being ruled out as the possible diagnosis. The nurse will identify which assessment and/or history data as supporting a diagnosis of pneumonia? Select all that apply. Cough Anorexia Chest pain Constipation Fever and Chills Purulent sputum History of COPDHeree Instruction:- Formulate nursing care plan A 58-year-old male patient came to the ER with the following chief complaints: “I can only walk about 50 steps before I become short of breath”. “I use 2 pillows at night to help me breathe.” Absent cough. Diminished breath sounds in bilateral lower lobes. BP 140/70 mmhg, RR 24 cpm, Temp. 98F 02 saturation 92%. Patient is a known chronic smoker with history of Chronic Obstructive Pulmonary Disorder. Patient was admitted and was hooked to oxygen support at 2 liters per minute via nasal cannula. He was also instructed to use Incentive Spirometer, 10 times every hour during waking hours only...?
- Kindly differentiate the below into the various nursing analysis phases: Assessment Diagnosis Planning Implementation & Rationale Evaluation Based on the provided information, a possible nursing diagnosis for this patient could be "Impaired Gas Exchange related to decreased oxygen saturation and presence of crackles in bilateral lower base of lungs." Rationale: The patient's shortness of breath, decreased oxygen saturation (93%), and presence of crackles indicate an impaired gas exchange, suggesting that the patient may be experiencing difficulties in oxygenation and ventilation. The chronic cough and thick yellowish sputum suggest an underlying respiratory condition that may contribute to impaired gas exchange. The patient's recent history of visiting the emergency department and being prescribed azithromycin and prednisone indicate a respiratory infection or exacerbation of a chronic respiratory condition. The nursing diagnosis of "Impaired Gas Exchange" is…Discuss and justify two nursing safety considerations/ interventions for patients receiving pre-operative medication while awaiting transfer to the operating room.Make an NCP, one actual and one potential from the nursing diagnoses given for high-risk infants: 1. Ineffective airway clearance related to presence of mucus or amniotic fluid in airway. 2. Ineffective thermoregulation related to newborn status and stress from birth weight variation. 3. Risk for infection related to lowered immune response in newborn. 4.Risk for imbalanced nutrition, less than body require- ments related to lack of energy for sucking.
- A 50-year-old client who has retired to the country has been diagnosed with emphysema. The symptoms include mild chronic cough, wheezing, and fatigue. During assessment, the client denies smoking or any history of smoking. The client mentions eating a well-balanced diet and regularly exercising. The client likes outdoor activities but is fatigued most of the time recently. The client is worried about the diagnosis and asks the nurse why this has happened. What kind of data provided by the client requires further validation? Give reasons. How should the nurse validate the client’s information and findings?A 50-year-old client who has retired to the country has been diagnosed with emphysema. The symptoms include mild chronic cough, wheezing, and fatigue. During assessment, the client denies smoking or any history of smoking. The client mentions eating a well-balanced diet and regularly exercising. The client likes outdoor activities but is fatigued most of the time recently. The client is worried about the diagnosis and asks the nurse why this has happened. What kind of data provided by the client requires further validation? Give 2. How should the nurse validate the client’s information and findings?When assessing a patient receiving a continuous opioid infu-sion, the nurse immediately notifies the physician when the patient has:a. A respiratory rate of 10/min with normal depthb. A sedation level of 4c. Mild confusiond. Reported constipation
- INSTRUCTIONS: Formulate a NURSING CARE PLAN based on a given scenario below. A 58-year-old male patient came to the ER with the following chief complaints: “I can only walk about 50 steps before I become short of breath”. “I use 2 pillows at night to help me breathe.” Absent cough. Diminished breath sounds in bilateral lower lobes. BP 140/70 mmhg, RR 24 cpm, Temp. 98F 02 saturation 92%. Patient is a known chronic smoker with history of Chronic Obstructive Pulmonary Disorder. Patient was admitted and was hooked to oxygen support at 2 liters per minute via nasal cannula. He was also instructed to use Incentive Spirometer, 10 times every hour during waking hours only.The nurse is providing care to a patient with a posterior pituitary tumor. The patient's vital signs are: B/P 100/70 mm Hg, HR 114, Respirations 20/min. Based on the findings, which prescription should the nurse anticipate? a. Initiate NPO status except for medications b. Redraw and confirm the client's laboratory values c. Increase the IV fluid administration rate d. Place client on bedrest with bathroom privilegesThe nurse is receiving an older adult client from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that the client has been agitated in the past following opioid administration. What principle should guide the nurse's management of the client's pain? a. The elderly may require lower doses of medication and are easily confused with new medications. b. The elderly may have altered absorption and metabolism, which prohibits the use of opioids. c. The elderly may be confused following surgery, which is an age-related phenomenon unrelated to the medication. d. The elderly may require a higher initial dose of pain medication followed by a tapered dose.