Podcast
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 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.
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.
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?
Which statement would the nurse utilize to identify the priority hypothesis?
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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 correction would be given to a new nurse who documents “Patient will ambulate 500 feet” for a patient admitted for an acute asthma exacerbation?
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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.
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.
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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?
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?
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For a patient returning to the unit postsurgery, which data would the nurse attribute to the hypothesis of Impaired Gas Exchange?
For a patient returning to the unit postsurgery, which data would the nurse attribute to the hypothesis of Impaired Gas Exchange?
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When developing hypotheses for a patient with oxygenation and perfusion problems, selection and individualization are dependent on which nursing activities?
When developing hypotheses for a patient with oxygenation and perfusion problems, selection and individualization are dependent on which nursing activities?
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Prioritize the nursing hypotheses for a newly admitted patient from highest priority to lowest priority.
Prioritize the nursing hypotheses for a newly admitted patient from highest priority to lowest priority.
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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?
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?
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Which patient-centered goal would be appropriate for a hypothesis of Impaired Airway Clearance for a patient with pneumonia?
Which patient-centered goal would be appropriate for a hypothesis of Impaired Airway Clearance for a patient with pneumonia?
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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 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?
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Which goal statement meets all goal-writing criteria?
Which goal statement meets all goal-writing criteria?
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Study Notes
Assessing for Palpitations
- The nurse should assess for:
- Chest pain
- Dyspnea
- Dizziness
- Syncope
- Fatigue
- Anxiety
- Medication use (especially stimulants or heart medications)
Impaired Airway Clearance
-
Expected findings:
- Cough
- Wheezing
- Dyspnea
- Rhonchi
- Crackles
- Increased respiratory rate
Matching Nursing Diagnoses with Cues
-
Impaired Gas Exchange:
- Low oxygen saturation
- High respiratory rate
- Increased heart rate
- Cyanosis
- Restlessness
-
Ineffective Airway Clearance:
- Cough
- Wheezing
- Dyspnea
- Production of sputum
-
Activity Intolerance:
- Fatigue
- Dyspnea on exertion
- Weak pulse
- Orthopnea (difficulty breathing while lying down)
Prioritizing Nursing Hypotheses
- The priority hypothesis is the one that poses the greatest immediate risk to the patient's well-being.
- Nursing assessment findings should be reviewed to identify the most life-threatening issue.
Correcting Documentation
- The nurse would correct documentation of "Patient will ambulate 500 feet" to indicate a specific distance and time, such as "Patient will ambulate 100 feet in 3 minutes."
- The nurse should consider the patient's abilities and safety when setting goals for ambulation.
Collaboration and COPD Exacerbation
-
Important team members for a patient with a COPD exacerbation:
- Respiratory therapist
- Pulmonologist
- Physical therapist
- Pharmacist
Increasing Fatigue in a Patient with Chronic Respiratory Disease
- Supporting nursing hypothesis is Activity Intolerance
-
Supporting evidence:
- Patient reports increasing fatigue and inability to perform ADLs.
- Patient walks slowly, stopping repeatedly to rest.
- Oxygen saturation drops as walking progresses.
- Respiratory rate is elevated.
Impaired Gas Exchange Post-Surgery
- **Data supporting Impaired Gas Exchange: **
- Decreased oxygen saturation
- Increased respiratory rate
- Wheezing
- Rales
- Restlessness
Individualizing Nursing Hypotheses
-
Selection and individualization of nursing hypotheses depend on:
- Patient's history and symptoms.
- Physical assessment findings.
- Lab results.
- Patient's goals.
Prioritizing Nursing Hypotheses for a Newly-Admitted Patient
-
Highest Priority:
- Airway (e.g., Impaired Gas Exchange, Ineffective Airway Clearance)
-
Next Highest Priority:
- Breathing (e.g., Impaired Gas Exchange, Ineffective Breathing Pattern)
-
Lowest Priority:
- Circulation (e.g., Decreased Cardiac Output, Reduced Tissue Perfusion)
Goal Development for a Patient with Anxiety before Cardiac Catheterization
-
Develop a patient-centered goal to reduce anxiety:
- "Patient will demonstrate reduced anxiety as evidenced by a respiratory rate less than 20 breaths per minute and a blood pressure within the normal range for the patient."
Goal for Impaired Airway Clearance for a Patient with Pneumonia
-
Patient-centered goal for Impaired Airway Clearance:
- "Patient will maintain clear breath sounds bilaterally as evidenced by the absence of wheezes, rales, and rhonchi."
Goal for a Patient with Reduced Peripheral Perfusion
-
Patient-centered goal for reduced peripheral perfusion:
- "Patient will demonstrate improved peripheral perfusion as evidenced by warm extremities, the ability to perform activities of daily living without frequent rest, and pink nail beds."
Goal-Writing Criteria
-
A goal statement meets all goal-writing criteria:
- It is patient-centered.
- It is measurable.
- It is attainable.
- It is realistic.
- It has a defined time frame.
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Description
This quiz focuses on identifying important cues for nurses to analyze when evaluating patients experiencing palpitations. Understanding these cues is crucial for accurate diagnosis and effective patient care.
