vSim rationales Flashcards
Expected assessment findings of a patient with pneumonia may include which of the following?
Fever, Malaise, Tachypnea, Use of accessory muscles
A patient in semi-Fowler’s position is having difficulty breathing. What is the priority action of the nurse?
raising the head of the bed will allow the patient to breathe more easily
The nurse titrates the patient’s oxygen to 3 L per nasal cannula in order to maintain an oxygen saturation of at least 94%, per the provider’s orders. What is the rationale for this order?
Promotes a decrease in respiratory effort, Promotes a decrease in myocardial workload, Allows the body to meet metabolic demands
A patient with newly diagnosed pneumonia has an oxygen saturation of 94% on room air, an increased respiratory rate, and an increased pulse. The patient is pale and anxious. The nurse questions the oxygen saturation results and looks up which of the following test results?
hemoglobin because it carries oxygen
While completing discharge instructions with a patient, the nurse notices the patient is short of breath. What is the priority nursing action at this time?
listen to the patient’s lungs because there might have been a change of status
A patient states he does not want to use the incentive spirometer because it makes him cough up too much sputum, and it is difficult to breathe. What is the correct information to teach the patient about the incentive spirometer?
The incentive spirometer helps you to maximize lung function and minimize the risk of your lung deflating
-the incentive spirometer inflates the alveoli
The nurse is preparing to collect a sputum specimen. Which of the following statement(s) are true?
A sputum specimen will show the presence of bacteria or another organism that may cause infection., Using a nebulizer may assist in obtaining a specimen.
-saliva would contaminate the specimen
Which diagnostic test serves as the basis for determining acid-base imbalances?
arterial blood gas
What pathology is responsible for metabolic acidosis?
a decrease in bicarbonate and an increase in hydrogen ions
The nurse is completing the physician’s orders by preparing the patient’s IV fluid therapy. When infusing supplemental potassium, the nurse knows that checking which of the following is the first priority before beginning the infusion?
potassium level
What determines the acidity of substances such as body fluids?
the number of existing H+ ions
