the nurse has received a shift report. which patient should the nurse assess first?

What does the nurse receive a change of shift report for?

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38 breaths/min c. A patient who has a cough productive of thick, green mucus d.

Which client should the nurse assess first?

Which client should the nurse assess first? 1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. 2. The client with a C-6 spinal cord injury who has autonomic dysreflexia.

What does a nurse note when assessing a patient after an accident?

Large bruised area on the chest When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

What does the nurse observe when the patient with respiratory disease?

The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to 88% while the patient is ambulating. What is the priority action of the nurse?

Which of the following clients should the nurse assess 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.

When triaging emergency room clients which client should the nurse assess first?

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.

Which client should be assigned to the most experienced nurse?

The most experienced nurse should be assigned to the client who requires teach- ing and evaluation of knowledge for home healthcare, because the client is in the surgery center for less than 1 day.

Which medication is most appropriate for the nurse to assign to the LPN to administer?

Which medication is most appropriate for the nurse to assign to the LPN to administer? -The sublingual nitroglycerin to the client who is complaining of chest pain.

In what order should the nurse assess assigned clients following shift Report place in priority order?

Terms in this set (59) In what order should the nurse assess assigned clients following shift report? Place in priority order.

Which client is the priority when triaging clients in the emergency department?

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.

What are the 4 steps of delegation in nursing?

4 Steps to Nursing DelegationKnow your resources. If you're not sure about which tasks can be delegated, know where to look this information up. ... Build rapport. ... Communicate clearly and respectfully. ... Don't forget to follow up.

When making assignments on a medical unit which client should the day shift charge nurse assign to the most experienced nurse?

The most experienced nurse should be assigned to the client who requires teaching and evaluation of knowledge for home healthcare, because the client is in the surgery center for less than 1 day. The charge nurse of a critical care unit is making assignments for the night shift.

What can nurses delegate?

An LPN may delegate tasks such as ambulating or feeding a patient to the CNA. The question of when a nurse should delegate is dependent on many factors. Usually, nurses delegate when they need help to prevent patient care delay.

Can LPN administer insulin?

The Licensed Practical Nurse can also give insulin injections, but it's good to keep in mind that some of these insulin medications can have very quick outcomes, so it is important for the nurse to assess before and after administering it.

What is the role of the LPN in the nursing process?

Under the supervision of a licensed registered nurse (RN) or physician, the LPN/LVN is accountable for the quality of nursing care he or she provides to patients and utilizing the nursing process, assumes responsibility for planning, implementing, and evaluating nursing care for assigned patients in the ...

Can LPN give im injection?

Of these levels of nursing, only a nurse practitioner is allowed to perform medical procedures in most states and, unfortunately for those who use LPNs to administer injections, most states recognize injections to be medical procedures. Therefore, LPNs should not be performing injections.

Which client should the emergency department triage nurse classify as emergent?

Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent.

Which injured client of a mass casualty disaster should a triage nurse in an emergency department establish as the priority client?

Victims with life-threatening injuries or illness (such as head injuries, severe burns, severe bleeding, heart-attack, breathing-impaired, internal injuries) are assigned a priority 1 or "Red" Triage tag code (meaning first priority for treatment and transportation).

What should an increased need for a rapid-acting bronchodilator alert the patient?

The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.

What does increased pulse, low oxygen saturation, tachypnea mean?

The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure. The nurse analyzes the results of a patient's arterial blood gases (ABGs).

What is Kussmaul respiration?

Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.

What is the priority of a bronchoscopy nurse?

Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to. suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes. before allowing the patient to take oral fluids or food.

Why should discharge instructions be postponed?

Because the patient is likely to be distracted just before discharge, giving discharge. instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic. than usual on the day of admission, so teaching about discharge should be postponed.

Is physical examination necessary for acute distress?

physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused. physical assessment should be done rapidly to help determine the cause of the distress and suggest. treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission.