after receiving shift report which patient would you assess first?

The nurse should use the ABCs to determine which order to assess the patients. The nurse should assess the 48-year-old patient with respiratory problems first (shortness of breath and pulse oximeter reading of 88%). Can a PCA change a colostomy bag?

Full Answer

When should the nurse instruct the client to perform the examination?

The nurse instructs the clients to perform the examination: A. At the onset of menstruation B. Every month during ovulation Rationale: The breast self-examination should be performed monthly 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended.

Which client should the nurse assess first for S3 heart sound?

The client with chronic renal failure who has an elevated creatinine level. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation.

How does the nurse determine whether the client is experiencing difficulty?

To determine whether the client currently is experiencing difficulty, the nurse asks the client about the presence of which early symptom? Rationale: Decreased force in the stream of urine is an early sign of benign prostatic hyperplasia. The stream later becomes weak and dribbling.

What does the staff nurse do to the patient before turning?

The staff nurse administers a mild analgesic before turning the patient. d. The staff nurse suctions the patient every 2 hours Suctioning increases intracranial pressure and is done only when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

Which patient should the nurse assess first after receiving a shift report?

The nurse has received the shift report. Which client should the nurse assess first? Assess the client for abnormal bleeding.

What immediate actions should the nurse implement when a client is having a myocardial infarction?

Administer oxygen along with medication therapy to assist with relief of symptoms. Encourage bed rest with the back rest elevated to help decrease chest discomfort and dyspnea.

What is the first intervention for a patient experiencing an MI?

The immediate concerns for a patient with suspected myocardial infarction should be their safety and comfort. Intravenous access must be available for effective administration of emergency drug therapy followed by rapid transfer to an area with a high level of supervision and resuscitation facilities.

Who should the nurse see first?

Maslow identifies five levels of human needs: physiological, safety or security, love and belonging, esteem, and self-actualization. Because physiological needs are necessary for survival, they have the highest priority and must be met first.

What is the most common complication of a myocardial infarction?

Ventricular free wall rupture. VFWR is the most serious complication of AMI. VFWR is usually associated with large transmural infarctions and antecedent infarct expansion. It is the most common cause of death, second only to LV failure, and it accounts for 15-30% of the deaths associated with AMI.

Which position is best for a client with heart failure who has Orthopnea?

Orthopnea is a symptom. You'll feel short of breath when you lie down. Sitting propped up on one or more pillows can improve your breathing.

What would be the primary goal of therapy for a client with pulmonary edema and heart failure quizlet?

The goals of therapy are to improve oxygenation, maintain an adequate blood pressure for perfusion of vital organs, and reduce excess extracellular fluid.

Which of the following blood tests is most indicative of cardiac damage?

A troponin test measures the levels of troponin T or troponin I proteins in the blood. These proteins are released when the heart muscle has been damaged, such as occurs with a heart attack. The more damage there is to the heart, the greater the amount of troponin T and I there will be in the blood.

What causes a drop in oxygen saturation in the blood?

Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of central venous blood. Information about the patient's body mass index, urinary output, and lipase will not help in determining the cause of the patient's drop in ScvO2.

Should ICU visitation be individualized?

ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.

Can family members remain in the room during CPR?

Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient. Click again to see term 👆.