components of health history
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Biographical information
Reason for seeking health care
Health history
Psychosocial history
Patient expectations
Present illness or health concerns
Family history
Spiritual health
pyrexia
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, fever
hypothermia temp
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less than 96.8
A patient signals the nurse by turning on the call light. The nurse enters the room and
finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the
intravenous (IV) line, and the patient asking questions about whether his doctor is
coming. Which of the following does the nurse perform first?
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Reconnect the drainage tubing
The nurse must reconnect the drainage tube for the priority of patient
safety. There is no reason to suspect a problem with the IV dressing unless
the fluid is not infusing on time. The nurse must prepare the next bottle of
solution after reconnecting the drainage tube. At that time the nurse can
check the condition of the IV dressing. As the nurse performs her care, she
can inform the patient about when the physician will round, unless she is
uncertain and needs to contact the physician.
A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with
deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital
signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2°
,F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula.
Which vital sign reflects a positive outcome of the oxygen therapy?
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Oxygen saturation: 96%
Oxygen saturation is an assessment of oxygen perfusion. Respiratory rate
assesses ventilation, radial pulse and blood pressure assess the
cardiovascular system, and temperature is an assessment of thermal
regulation.
Tips on Using Reflection
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Common Bowel Elimination Problems
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constipation, impaction, diarrhea, incontinence, flatulence, hemorrhoids
, The nurse observes a nursing student taking a blood pressure (BP) on a patient. The
nurse notes that the student very slowly deflates the cuff in an attempt to hear the
sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg.
Which of the following BP readings made by the student is most likely caused by an
incorrect technique?
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130/90 mm Hg
Deflating the cuff too slowly will result in a false-high diastolic blood
pressure.
nursing-sensitive patient outcome
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A measurable patient, family, or community state, behavior, or perception
largely influenced by and sensitive to nursing interventions
ex: reduction in pain frequency and severity, incidence of pressure ulcers
Which of the following does a nurse perform when discontinuing a plan of care for a
patient?
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Biographical information
Reason for seeking health care
Health history
Psychosocial history
Patient expectations
Present illness or health concerns
Family history
Spiritual health
pyrexia
Give this one a try later!
, fever
hypothermia temp
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less than 96.8
A patient signals the nurse by turning on the call light. The nurse enters the room and
finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the
intravenous (IV) line, and the patient asking questions about whether his doctor is
coming. Which of the following does the nurse perform first?
Give this one a try later!
Reconnect the drainage tubing
The nurse must reconnect the drainage tube for the priority of patient
safety. There is no reason to suspect a problem with the IV dressing unless
the fluid is not infusing on time. The nurse must prepare the next bottle of
solution after reconnecting the drainage tube. At that time the nurse can
check the condition of the IV dressing. As the nurse performs her care, she
can inform the patient about when the physician will round, unless she is
uncertain and needs to contact the physician.
A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with
deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital
signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2°
,F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula.
Which vital sign reflects a positive outcome of the oxygen therapy?
Give this one a try later!
Oxygen saturation: 96%
Oxygen saturation is an assessment of oxygen perfusion. Respiratory rate
assesses ventilation, radial pulse and blood pressure assess the
cardiovascular system, and temperature is an assessment of thermal
regulation.
Tips on Using Reflection
Give this one a try later!
Common Bowel Elimination Problems
Give this one a try later!
constipation, impaction, diarrhea, incontinence, flatulence, hemorrhoids
, The nurse observes a nursing student taking a blood pressure (BP) on a patient. The
nurse notes that the student very slowly deflates the cuff in an attempt to hear the
sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg.
Which of the following BP readings made by the student is most likely caused by an
incorrect technique?
Give this one a try later!
130/90 mm Hg
Deflating the cuff too slowly will result in a false-high diastolic blood
pressure.
nursing-sensitive patient outcome
Give this one a try later!
A measurable patient, family, or community state, behavior, or perception
largely influenced by and sensitive to nursing interventions
ex: reduction in pain frequency and severity, incidence of pressure ulcers
Which of the following does a nurse perform when discontinuing a plan of care for a
patient?
Give this one a try later!
