Nurse Patricia is caring for a patient with Pulmonary Tuberculosis in the emergency room. The hospital doesn't have any private room for isolation. Explain your answer with the theory provided. 1. What is the best nursing action of Nurse Patricia in line with the Environmental Theory.
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- A nurse is assessing the vital signs of patients who presentedat the emergency department. Based on the knowledge ofage-related variations in normal vital signs, which patientswould the nurse document as having a normal vital sign?Select all that apply.a. A 4-month old infant whose temperature is 38.1°C(100.5°F)b. A 3-year old whose blood pressure is 118/80c. A 9-year old whose temperature is 39°C (102.2°F)d. An adolescent whose pulse rate is 70 bpme. An adult whose respiratory rate is 20 bpmf. A 72-year old whose pulse rate is 42 bpmA nurse orients an older patient to the safety features in herhospital room. What is a priority component of this admissionroutine?a. Explain how to use the telephone.b. Introduce the patient to her roommate.c. Review the hospital policy on visiting hours.d. Explain how to operate the call bell.The nurse is administering medication to a patient who has tuberculosis . The patient refuses the medication . The nurse understands which of the following is true regarding the patient's autonomous rights ? A. Patients can refuse any or all treatments B. Patient's Self -Determination Act guarantees the right to refuse all treatments C. Legal systems can force patients to take medication for contagious diseases D. Health care systems cannot force patient to take medications for contagious diseases
- To develop a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention? a. Encourage patient intake of 3000 ml/day of fluids if not contraindicated. b. Encourage early ambulation and patient to eat meals in beside chair. c. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake. d. Repositioning every 3-4 hoursA nurse is monitoring a patient who is receiving an IVinfusion of normal saline. The patient is apprehensive andpresents with a pounding headache, rapid pulse rate, chills,and dyspnea. What would be the nurse’s priority interventionrelated to these symptoms?a. Discontinue the infusion immediately, monitor vitalsigns, and report findings to primary care providerimmediately.b. Slow the rate of infusion, notify the primary care providerimmediately and monitor vital signs.c. Pinch off the catheter or secure the system to prevent entryof air, place the patient in the Trendelenburg position, andcall for assistance.d. Discontinue the infusion immediately, apply warm, moistcompresses to the site, and restart the IV at another site.A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient dis-plays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse’s priority actions related to thesesymptoms?a. Slow or stop the infusion; monitor vital signs, notify thephysician, place the patient in upright position with feetdependent.b. Stop the transfusion immediately and keep the vein openwith normal saline, notify the physician stat, administerantihistamine parenterally as needed.c. Stop the transfusion immediately and keep the veinopen with normal saline, notify the physician, andtreat symptoms.d. Stop the infusion immediately, obtain a culture of thepatient’s blood, monitor vital signs, notify the physician,administer antibiotics stat.
- While discussing home safety with the nurse, a patient admitsthat she always smokes a cigarette in bed before falling asleepat night. Which nursing diagnosis would be the priority forthis patient?a. Impaired Gas Exchange related to cigarette smokingb. Anxiety related to inability to stop smokingc. Risk for Suffocation related to unfamiliarity with fireprevention guidelinesd. Deficient Knowledge related to lack of follow-through ofrecommendation to stop smokingA nurse providing care of a patient’s chest drainage systemobserves that the chest tube has become separated from thedrainage device. What would be the first action that shouldbe taken by the nurse in this situation?a. Notify the physician.b. Apply an occlusive dressing on the site.c. Assess the patient for signs of respiratory distress.d. Put on gloves and insert the chest tube in a bottle of sterilesaline.A nurse is teaching a patient how to use a meter-dosedinhaler for her asthma. Which comments from the patientassure the nurse that the teaching has been effective? Selectall that apply.a. “I will be careful not to shake up the canister beforeusing it.”b. “I will hold the canister upside-down when using it.” c. “I will inhale the medication through my nose.”d. “I will continue to inhale when the cold propellant is in mythroat.”e. “I will only inhale one spray with one breath.”f. “I will activate the device while continuing to inhale.”