Oxygenation and Perfusion: Analyze Cues and Prioritize Hypotheses; Plan and Generate Solutions__Wk2_

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Which cues would be important for the nurse to analyze in a patient with palpitations? Select all that apply.

Chest pain (correct)

Wheezing

Pneumonia

Electrocardiogram (ECG) changes (correct)

Which cues would the nurse expect to identify when providing care for a patient with Impaired Airway Clearance? Select all that apply.

Chest pain

Pneumonia (correct)

Thick sputum (correct)

Diminished bilateral breath sounds (correct)

Match each nursing diagnosis with the associated patient cue.

Low oxygen saturation and arterial oxygen levels = Ineffective Tissue Perfusion Complaints of fatigue, dropping oxygen saturation with walking = Activity Intolerance Cough with thick, green sputum = Impaired Airway Clearance Diaphoresis and increased respiratory rate = Acute chest pain

Which statement would the nurse utilize to identify the priority hypothesis?

The priority hypothesis is one that, if not attended to, will cause harm or increased threat to the patient. Signup and view all the answers

Which correction would be given to a new nurse who documents “Patient will ambulate 500 feet” for a patient admitted for an acute asthma exacerbation?

The goal should be time-limited. Signup and view all the answers

Which team members would the nurse collaborate with when caring for a patient with an acute chronic obstructive pulmonary disease (COPD) exacerbation? Select all that apply.

Dietitian Signup and view all the answers

A patient with a chronic respiratory disease reports increasing fatigue and inability to perform activities of daily living (ADLs). The nurse notes that the patient walks slowly, stopping repeatedly to rest; oxygen saturation drops as walking progresses; respiratory rate is elevated; no adventitious breath sounds are heard; and the patient denies pain. Which nursing hypothesis would be supported by this evidence?

Activity Intolerance Signup and view all the answers

For a patient returning to the unit postsurgery, which data would the nurse attribute to the hypothesis of Impaired Gas Exchange?

Oxygen saturation (SpO2) less than 90% Signup and view all the answers

When developing hypotheses for a patient with oxygenation and perfusion problems, selection and individualization are dependent on which nursing activities?

Appropriate data clustering Signup and view all the answers

Prioritize the nursing hypotheses for a newly admitted patient from highest priority to lowest priority.

(1) Highest priority = Impaired Airway Clearance (2) Priority = Impaired Gas exchange (3) Low priority = Impaired Peripheral Tissue Perfusion (4),(5),(6) Lowest priority = Acute chest pain, Activity Intolerance, Anxiety Signup and view all the answers

When assessing a patient scheduled for a cardiac catheterization, the patient voices anxiety. Assessment findings are: temperature 98.3°F, respirations 24 breaths per minute, and blood pressure 150/80 mm Hg. Which patient-centered goal would the nurse develop at this time?

Patient will report a decrease in anxiety with a respiratory rate of 16 to 20 breaths per minute before surgery. Signup and view all the answers

Which patient-centered goal would be appropriate for a hypothesis of Impaired Airway Clearance for a patient with pneumonia?

Patient will maintain a patent airway throughout the day. Signup and view all the answers

Which goal would the nurse develop for a patient with extremities that are cool to touch, inability to perform activities of daily living without frequent rest, and cyanotic nail beds?

Patient will maintain oxygen saturation (SpO2) at 92% or greater on room air by the end of the shift. Signup and view all the answers

Which goal statement meets all goal-writing criteria?

Patient will maintain SpO2 at 92% on room air or greater with activity within 48 hours. Signup and view all the answers

Oxygenation and Perfusion: Analyze Cues and Prioritize Hypotheses; Plan and Generate SolutionsWk2Sherpath

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Questions and Answers

Which cues would be important for the nurse to analyze in a patient with palpitations? Select all that apply.

Which cues would the nurse expect to identify when providing care for a patient with Impaired Airway Clearance? Select all that apply.

Match each nursing diagnosis with the associated patient cue.

Which statement would the nurse utilize to identify the priority hypothesis?

Which correction would be given to a new nurse who documents “Patient will ambulate 500 feet” for a patient admitted for an acute asthma exacerbation?

Which team members would the nurse collaborate with when caring for a patient with an acute chronic obstructive pulmonary disease (COPD) exacerbation? Select all that apply.

For a patient returning to the unit postsurgery, which data would the nurse attribute to the hypothesis of Impaired Gas Exchange?

When developing hypotheses for a patient with oxygenation and perfusion problems, selection and individualization are dependent on which nursing activities?

Prioritize the nursing hypotheses for a newly admitted patient from highest priority to lowest priority.

When assessing a patient scheduled for a cardiac catheterization, the patient voices anxiety. Assessment findings are: temperature 98.3°F, respirations 24 breaths per minute, and blood pressure 150/80 mm Hg. Which patient-centered goal would the nurse develop at this time?

Which patient-centered goal would be appropriate for a hypothesis of Impaired Airway Clearance for a patient with pneumonia?

Which goal would the nurse develop for a patient with extremities that are cool to touch, inability to perform activities of daily living without frequent rest, and cyanotic nail beds?

Which goal statement meets all goal-writing criteria?

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Oxygenation and Perfusion: Analyze Cues and Prioritize Hypotheses; Plan and Generate Solutions__Wk2__Sherpath

Podcast Beta

Questions and Answers

Which cues would be important for the nurse to analyze in a patient with palpitations? Select all that apply.

Which cues would the nurse expect to identify when providing care for a patient with Impaired Airway Clearance? Select all that apply.

Match each nursing diagnosis with the associated patient cue.

Which statement would the nurse utilize to identify the priority hypothesis?

Which correction would be given to a new nurse who documents “Patient will ambulate 500 feet” for a patient admitted for an acute asthma exacerbation?

Which team members would the nurse collaborate with when caring for a patient with an acute chronic obstructive pulmonary disease (COPD) exacerbation? Select all that apply.

For a patient returning to the unit postsurgery, which data would the nurse attribute to the hypothesis of Impaired Gas Exchange?

When developing hypotheses for a patient with oxygenation and perfusion problems, selection and individualization are dependent on which nursing activities?

Prioritize the nursing hypotheses for a newly admitted patient from highest priority to lowest priority.

When assessing a patient scheduled for a cardiac catheterization, the patient voices anxiety. Assessment findings are: temperature 98.3°F, respirations 24 breaths per minute, and blood pressure 150/80 mm Hg. Which patient-centered goal would the nurse develop at this time?

Which patient-centered goal would be appropriate for a hypothesis of Impaired Airway Clearance for a patient with pneumonia?

Which goal would the nurse develop for a patient with extremities that are cool to touch, inability to perform activities of daily living without frequent rest, and cyanotic nail beds?

Which goal statement meets all goal-writing criteria?

More Like This

Nursing Assessment Quiz

Nursing Assessment and Patient Care

Nursing Assessment in Polycythemia Vera

Nursing Assessment Chapter 6

Oxygenation and Perfusion: Analyze Cues and Prioritize Hypotheses; Plan and Generate SolutionsWk2Sherpath