12 hours ago · The nurse receives a handoff report on four patients. Which patient should the nurse assess first? Answer: Pulse 42 beats per minute. The nurse would identify which patient as having a problem of impaired gas exchange secondary to a perfusion problem? A patient with Answer: peripheral arterial disease of the lower extremities Reason: Perfusion ... >> Go To The Portal
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death.
The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client's: a) respiratory status. b) level of consciousness.
A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider.
The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first?
Which of the following clients should the nurse assess first? *When using the acute versus chronic approach to client care, the nurse should place the priority on the client who has a chest tube and has asymmetrical chest movement because this can indicate a tension pneumothorax.
Which client should the nurse on the vascular unit assess first after receiving the shift report? The client with an above the knee amputation who needs a full body lift to get in the wheelchair. The charge nurse of a long-term care facility is making assignments.
Nurse triage is needed in a number of situations, including within the emergency department. The nurse must assess which client is at the highest risk of being in a life-threatening situation. The first client who must be assessed is the one who has a situation that threatens the airway, breathing, or circulation.
Terms in this set (59) In what order should the nurse assess assigned clients following shift report? Place in priority order.
Who Can/Should file a complaint with the Board of Registered Nursing?gross negligence or incompetence.unprofessional conduct.license application fraud.misrepresentation.substance abuse.mental illness.unlicensed activity.
Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries.
A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.
Category 4. A non-urgent problem, such as stable clinical cases, which requires transportation to a hospital ward or clinic.
Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (i.e., gloves) prior to care. This takes priority over calling law enforcement. Requesting blood bank products can be delegated. The nurse may or may not have to prepare the client for emergency surgery.
A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago.
Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation. 5. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic.