NUR 225 Exam 2 – Questions With Expert Solutions
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Terms in this set (50)
, Ms. Kelley is a 47-year-old female
admitted to the post-surgical unit
following removal of her gallbladder.
She has a history of hyperlipidemia
(elevated serum lipids), depression, and
asthma (lung disease that causes
bronchoconstriction, coughing, and
thick bronchial secretions). Ms. Kelley's
vital signs are T 37.9° C (100.2° F), P 112
and regular, R 24 shallow and labored,
BP 142/88, and continuous pulse
oximetry reading of 89% on 2 liters of
oxygen via nasal cannula. The patient
denies pain but states that her chest
feels "heavy." Lung auscultation reveals
adventitious breath sounds (expiratory
wheezes) with diminished sounds
bilaterally at the lung bases. The patient
appears restless and slightly
diaphoretic. She asks you, "Why does
the machine keep beeping?" Her
abdomen is flat but tender from the
surgical puncture sites. Her dressings
are clean, dry, and intact.
The nurse writes "Ineffective airway Bronchoconstriction
clearance" as the beginning of a nursing
diagnosis. Based on Ms. Kelley's data, Increased production of mucus
what should be written in the "related
to" to portion of the statement?
The nurse is admitting Ms. Kelley. How Ineffective airway clearance
should the nurse prioritize Ms. Kelley's Impaired gas exchange
nursing diagnoses? Begin with the Ineffective peripheral tissue perfusion
highest priority diagnosis first. Acute pain
Activity intolerance
Anxiety
Add to calendar
Play your way to mastery with fun games
Match Blocks Charms NEW
Terms in this set (50)
, Ms. Kelley is a 47-year-old female
admitted to the post-surgical unit
following removal of her gallbladder.
She has a history of hyperlipidemia
(elevated serum lipids), depression, and
asthma (lung disease that causes
bronchoconstriction, coughing, and
thick bronchial secretions). Ms. Kelley's
vital signs are T 37.9° C (100.2° F), P 112
and regular, R 24 shallow and labored,
BP 142/88, and continuous pulse
oximetry reading of 89% on 2 liters of
oxygen via nasal cannula. The patient
denies pain but states that her chest
feels "heavy." Lung auscultation reveals
adventitious breath sounds (expiratory
wheezes) with diminished sounds
bilaterally at the lung bases. The patient
appears restless and slightly
diaphoretic. She asks you, "Why does
the machine keep beeping?" Her
abdomen is flat but tender from the
surgical puncture sites. Her dressings
are clean, dry, and intact.
The nurse writes "Ineffective airway Bronchoconstriction
clearance" as the beginning of a nursing
diagnosis. Based on Ms. Kelley's data, Increased production of mucus
what should be written in the "related
to" to portion of the statement?
The nurse is admitting Ms. Kelley. How Ineffective airway clearance
should the nurse prioritize Ms. Kelley's Impaired gas exchange
nursing diagnoses? Begin with the Ineffective peripheral tissue perfusion
highest priority diagnosis first. Acute pain
Activity intolerance
Anxiety
