The nurse is assessing a 6-year-old male client with a histo…

The nurse is assessing a 6-year-old male client with a history of asthma who was brought to the emergency department (ED) and reports shortness of breath during a soccer game. The nurse completes a triage assessment with the following data. Vitals Temperature                      99.20 FHeart Rate                         96Respirations                      32Blood pressure                 97/66Oxygen saturation           89% (on room air) Health History Born at 30 Weeks History of Asthma Multiple environmental allergies Allergic to penicillin Immunizations are current Physical/Psychosocial Assessment Findings Child reports no pain Child is restless and refuses to lie down in bed Wheezing in both lungs Minimal air movement noted in lower lobes bilaterally Child only nods head “yes” or “no” to questions Parents are at the bedside and providing comfort Parents deny that the child was exposed to any triggers Moderate intercostal retractions present   Indicated if urgent follow up by the nurse is necessary (immediate follow up needed) or not necessary (no immediate follow up needed). 1. Temperature of 99.20F [option1] 2. Oxygen Saturation of 89% (on room air) [option2] 3. Allergy to penicillin [option3] 4. Wheezing in the lungs [option4] 5. Respirations of 32 [option5] 6. Parents deny the child was exposed to any triggers [option6]

Optional Feedback (2 points for completing all 6 of these qu…

Optional Feedback (2 points for completing all 6 of these questions): 1 Identify the study tool that helped you prepare MOST for all exams in this class: [1] 2 Identify something you did to improve from exam 1 to 2 or 2 to 3: [2] 3. Offer one piece of advice to someone who is taking this class in the future so that they can be successful: [3] 4. Identify one aspect of the class you liked most: [4] 5. Identify one component (this could be a topic, study tool, how the class is formatted/offered, TA help, mode of instruction, etc.) that could be improved in this class for future semester offerings: [5] 6. What is one thing that you overcame in this learning environment [6a] and one thing was challenging for you about this learning environment [6b]. THANK YOU ALL SO MUCH FOR A GREAT SEMESTER! I WISH YOU ALL THE LUCK AS YOU MOVE ON! AND REMEMBER…  BE GOOD TO EACH OTHER AND YOURSELF! – DOC HILL

The nurse is caring for a client who presents to the Emergen…

The nurse is caring for a client who presents to the Emergency Department following a motor vehicle accident. The nurse documents the initial assessment findings below.  Vital Signs  Assessment Findings  99.8 F  110 beats per minute  24 breaths per minute, labored  90/72 mmHg  87% on 2L/min per nasal cannula  Pain rated 8/10  Bruising noted over client’s left chest  Auscultation of left chest reveals absent breath sounds  Jugular venous distention noted  Client trachea appears deviated to the right  After contacting the healthcare provider, the client is diagnosed with spontaneous pneumothorax. A needle decompression takes place, along with chest tube insertion into the left 2nd intercostal space which is connected to a closed drainage system. Based on the diagnosis, identify whether the interventions listed below are indicated or contraindicated for the client.  Clamp the client’s chest tube prior to transferring the client to the radiology department [intervention1] Monitor for tidaling that is consistent with client’s respirations [intervention2] Assess the chest tube and drainage system once every shift [intervention3]  Keep the drainage system lower than the level of the chest [intervention4] Educate client that they can remove the drainage system when ambulating to the bathroom [intervention5] 

Arterial Blood Gas Reference Range pH PaC02 HC03 Pa0…

Arterial Blood Gas Reference Range pH PaC02 HC03 Pa02 7.35-7.45 35-45 mmHG 22-26 mEq/L 80-110 mmHG   The arterial blood gasses of a patient with severe chronic obstructive pulmonary disease (COPD) are: pH: 7.34, PaO2: 80 mmHg, PaCO2: 47 mmHg, HCO3: 28 mEq/L. Based on these findings, what is the priority action of the nurse?