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Clinical Nursing Skills

What Should the Nurse Do?

Clinical Nursing SkillsWhat Should the Nurse Do?

What Should the Nurse Do?

1 .
The day-shift nurse enters a patient’s room just after receiving report from the night-shift nurse. The patient is leaning over the bedside table, eating breakfast, and talking on the phone to a family member. Food is dribbling out of the patient’s mouth and onto the gown. When the nurse enters the room, the patient gets off the phone and says to the nurse, “What do you have for me today?” Which findings would require further investigation by the nurse?
  1. interaction with family member
  2. dribbling food
  3. client’s statement
  4. client’s posture
2 .
A nurse is providing discharge instructions for a patient with a BMI of 31. The patient was admitted for an appendectomy and holds a job as a full-time construction worker and part-time mover. Which should be included in the patient’s postoperative plan and why: decrease or increase caloric intake?
3 .
A nurse is obtaining vital signs on a patient recovering from a total knee replacement. The patient has just returned from a physical therapy session. The patient’s trends for hospital stay include the following ranges:
  • Temperature: 97.2°F (36.2°C) to 99.1°F (37.3°C)
  • Heart rate: 64 to 82
  • Respiratory rate: 16 to 22
  • Blood pressure: 128 to 146/70 to 72
  • The nurse obtains the following vital signs:
  • Temperature: 96.9°F (36.1°C)
  • Heart rate: 80
  • Respiratory rate: 22
  • Blood pressure: 102/50
  • Which should be the nurse’s first action?
4 .
A nurse is caring for a patient recovering from spinal surgery on postoperative day 1. The patient’s medical history includes type 2 diabetes mellitus and high cholesterol. The patient is currently receiving pain medications: oral ibuprofen every eight hours and IV morphine via a patient-controlled analgesia pump. The nurse obtains the patient’s vital signs while the patient is sleeping and notes an abnormal respiratory rate of 8 breaths per minute. What may be the cause of the abnormal respiratory rate?
  1. diabetic ketoacidosis
  2. opioid use
  3. pain leading to atelectasis
  4. severed innervation to the diaphragm
A nurse on the medical unit is caring for four patients and just received the vital sign data from the patient care tech. The patient care tech used a digital vital sign machine and a standard adult cuff for all the patients but made sure to clean it between each use.
  • Patient 1: A patient admitted with kidney stones awaiting stent placement. T 99.1, P 104, RR 20, BP 136/82, Oxygen saturation 100 percent on room air
  • Patient 2: A patient admitted with heart failure with pulmonary edema. T 97.1, P 110, RR 24, BP 88/42, Oxygen saturation 91 percent on 2 L of oxygen
  • Patient 3: A patient admitted with chronic renal failure and atherosclerosis. T 98.2, P 90, RR 18, BP 175/101, Oxygen saturation 97 percent on room air
  • Patient 4: An older adult patient admitted with failure to thrive. T 96.9, P 68, RR 18, BP 92/49, Oxygen saturation 96 percent on room air
5 .
Who should the nurse see first and why?
6 .
What intervention should the nurse provide for patient 4 and why?

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