swift river (Arthur Thomason,
Charlie Raymond,Dotty
Hamilton,Hildegard Lowe,Wight
Goodman,Ramona Stukes)
Arthur Thomason
Arthur Thomason is a 56-year-old client who was involved in a
motor vehicle crash (MVC). The client is four days post-operative
for splenectomy and femur repair. Arthur is experiencing new
onset of shortness of breath and is on oxygen at 2 L/min via nasal
cannula with SpO2 at 89%. The client is restless with slight
confusion but easily orientated x 3. Temperature spiked during
the night to 39.1° C (102.4° F) and last temperature check was
38° C (101° F); BP now 146/94 mm Hg, which is slightly elevated
from the client's baseline; respirations at 30/min and slightly
labored; heart rate 102/min versus 84/min from last night's shift.
Skin cool to touch and appears pale. Unproductive coughing to
,clear their airway. Recent chest X-ray shows diffuse bilateral
interstitial infiltrates in all lobes. Recent blood gases demonstrate
falling PaO2 (hypoxemia) and increasing CO2 (hypercapnia). The
client appears anx - ✔ANASWER✔-Maslow's Hierarchy of Needs
Your response: High Priority
Airway, Breathing, Circulation
Your response: High Priority
Safety and Risk Reduction
Your response: High Priority
Urgent vs Nonurgent; high
Chronic vs Acute/Stable vs Unstable- high
Initial Nursing Assessment
Arthur Thomason is a 56-year-old client who was involved in a
motor vehicle accident (MVA). The client is four days post-
operative for splenectomy and femur repair. Arthur is
experiencing new onset of shortness of breath and is on oxygen
at 2 L/min via nasal cannula with SpO2 at 89%. The client is
restless with slight confusion but easily orientated x 3.
Temperature spiked during the night to 39.1° C (102.4° F) and
last temperature check was 38° C (101°F); BP now 146/94 mm
,Hg, which is slightly elevated from the client's baseline;
respirations at 30/min and slightly labored; heart rate 102/min
versus 84/min from last night's shift. Skin cool to touch and
appears pale. Unproductive coughing to clear their airway. Recent
chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes.
Recent blood gases demonstrate falling PaO2 (hypoxemia) and
increasing CO2 (hypercapnia). The clie - ✔ANASWER✔-
Physiological: Gas Exchang,
Physiological: Acid Base
Physiological: Thermoregulation
Psychosocial: Cognition
Physiological: Comfort
Psychosocial: Stress and Coping
Physiological: Perfusion
Arthur Thomason
After receiving hand-off report, the nurse enters the client's room
and observes the client talking to self. The nurse greets the client
and introduces self but notices the client appears confused. The
nurse provides reorientation to the client who is lying in supine
, position with their nasal cannula not on properly. The client is
dyspneic at rest and appears restless.
Which of the following actions should the nurse take? (Select all
that apply.) - ✔ANASWER✔-Check the client's oxygen saturation
level.
Place the nasal cannula on the client properly.
Assist client to high-Fowler's position
Arthur Thomason
The nursing assessment reveals lungs sounds with crackles
auscultated bilaterally; respirations 29/min on oxygen at 4 L/min.
IV of D5LR infusing to left hand at 75 mL/hr without signs of
infiltration. Oral mucosa moist, skin pale and cool to touch.
Indwelling urinary catheter draining yellow urine with 70 mL
collected in two hours. Vital signs temperature 38.5°C (101.3° F);
blood pressure 148/92 mm Hg; heart rate 105/min; respirations
30/min and slightly labored; SpO2 89% on 4 L/min of oxygen. The
client reports "feeling funny" with some discomfort and appears
anxious. Denies pain.
Which of the following provider's prescriptions should the nurse
anticipate? (Select all that apply.) - ✔ANASWER✔-Obtain arterial
blood gases stat.
Maintain strict intake and output.
Charlie Raymond,Dotty
Hamilton,Hildegard Lowe,Wight
Goodman,Ramona Stukes)
Arthur Thomason
Arthur Thomason is a 56-year-old client who was involved in a
motor vehicle crash (MVC). The client is four days post-operative
for splenectomy and femur repair. Arthur is experiencing new
onset of shortness of breath and is on oxygen at 2 L/min via nasal
cannula with SpO2 at 89%. The client is restless with slight
confusion but easily orientated x 3. Temperature spiked during
the night to 39.1° C (102.4° F) and last temperature check was
38° C (101° F); BP now 146/94 mm Hg, which is slightly elevated
from the client's baseline; respirations at 30/min and slightly
labored; heart rate 102/min versus 84/min from last night's shift.
Skin cool to touch and appears pale. Unproductive coughing to
,clear their airway. Recent chest X-ray shows diffuse bilateral
interstitial infiltrates in all lobes. Recent blood gases demonstrate
falling PaO2 (hypoxemia) and increasing CO2 (hypercapnia). The
client appears anx - ✔ANASWER✔-Maslow's Hierarchy of Needs
Your response: High Priority
Airway, Breathing, Circulation
Your response: High Priority
Safety and Risk Reduction
Your response: High Priority
Urgent vs Nonurgent; high
Chronic vs Acute/Stable vs Unstable- high
Initial Nursing Assessment
Arthur Thomason is a 56-year-old client who was involved in a
motor vehicle accident (MVA). The client is four days post-
operative for splenectomy and femur repair. Arthur is
experiencing new onset of shortness of breath and is on oxygen
at 2 L/min via nasal cannula with SpO2 at 89%. The client is
restless with slight confusion but easily orientated x 3.
Temperature spiked during the night to 39.1° C (102.4° F) and
last temperature check was 38° C (101°F); BP now 146/94 mm
,Hg, which is slightly elevated from the client's baseline;
respirations at 30/min and slightly labored; heart rate 102/min
versus 84/min from last night's shift. Skin cool to touch and
appears pale. Unproductive coughing to clear their airway. Recent
chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes.
Recent blood gases demonstrate falling PaO2 (hypoxemia) and
increasing CO2 (hypercapnia). The clie - ✔ANASWER✔-
Physiological: Gas Exchang,
Physiological: Acid Base
Physiological: Thermoregulation
Psychosocial: Cognition
Physiological: Comfort
Psychosocial: Stress and Coping
Physiological: Perfusion
Arthur Thomason
After receiving hand-off report, the nurse enters the client's room
and observes the client talking to self. The nurse greets the client
and introduces self but notices the client appears confused. The
nurse provides reorientation to the client who is lying in supine
, position with their nasal cannula not on properly. The client is
dyspneic at rest and appears restless.
Which of the following actions should the nurse take? (Select all
that apply.) - ✔ANASWER✔-Check the client's oxygen saturation
level.
Place the nasal cannula on the client properly.
Assist client to high-Fowler's position
Arthur Thomason
The nursing assessment reveals lungs sounds with crackles
auscultated bilaterally; respirations 29/min on oxygen at 4 L/min.
IV of D5LR infusing to left hand at 75 mL/hr without signs of
infiltration. Oral mucosa moist, skin pale and cool to touch.
Indwelling urinary catheter draining yellow urine with 70 mL
collected in two hours. Vital signs temperature 38.5°C (101.3° F);
blood pressure 148/92 mm Hg; heart rate 105/min; respirations
30/min and slightly labored; SpO2 89% on 4 L/min of oxygen. The
client reports "feeling funny" with some discomfort and appears
anxious. Denies pain.
Which of the following provider's prescriptions should the nurse
anticipate? (Select all that apply.) - ✔ANASWER✔-Obtain arterial
blood gases stat.
Maintain strict intake and output.
