NCLEX- SAUNDERS COMPREHENSIVE REVIEW|UPDATED&VERIFIED|100% SOLVED|GUARANTEED SUCCESS

the nurse is caring for a patient with a diagnosis of heart failure who suddenly complains about shortness of breath and dyspnea. the nurse should take which immediate action elevate the head of the patients bed early sign of hypovolemic shock increased pulse rate What should you consider when selecting an answer or determining the order of priority using ABCs A-airway B-breathing C-circulation (exception: CPR. then remember CAB- compression, airway, breathing) use maslow hierarchy of needs theory when prioritizing 1). basic physiological need 2). safety and security 3). love and belonging 4). self esteem 5). self actualization use the steps of the nursing process to prioritize assessment analysis planning implementation evaluation eliminate options that contain closed ended words- all, always, every, must, none open-ended words could possible be the correct answer may, usually, normal, commonly, or generally look for the umbrella option a broad or universal option respect for an individuals right to self-determination Autonomy the obligation to do or cause no harm to another nonmaleficence the duty to do good to others and to maintain a balance between benefits and harm beneficence the duty to do what one has promised fidelity obligation to tell the truth veracity examples of negligent acts medication errors that result in injury to client IV administration errors, such as incorrect flow rates or failure to monitor flow rate, that results in injury to client... pg. 136 instructional directives living wills required to be written and signed by the client defamation false communication writing- libel verbally- slander determines whether the client has a conductive or sensorineural hearing loss weber test air conduction is normally hear twice as long than bone conduction rinne test equilibrium test romberg test swaying is a postive romberg sign palpable vibration of the chest wall resulting from speech Tactile Fremitus abnormal breath sounds adventitious sounds high pitched crackling and popping noises (discontinuous sounds) heard during the end of inspiration. not cleared by cough -clinical example: fine crackles (fine rales) -may be heard in pneumonia, heart failure, asthma, restrictive pulmonary disease medium pitched, moist sound heard about halfway through inspiration. not cleared by cough -clinical examples medium crackles (medium rales) -same as fine crackles but conditions have worsen low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration -clinical examples: coarse crackles (coarse rales) -same as medium and fine but is even worse than both or is heard in terminally ill clients with diminished gag reflex. also heard in pulmonary edema and pulmonary fibrosis high-pitched, musical sound similar to a squeak. heard more commonly during expiration, but may also be heard during inspiration. occurs only in small airway -clinical examples: Wheeze (sibilant wheeze) -heard in narrowed airway diseases such as asthma low-pitched, coarse, loud, low snoring or moaning tone. heard primarily during expiration but may be heard during inspiration. coughing my clear Rhonchi (sonorous wheeze)` -heard in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis