The nurse is caring for a client who is having shortness of breath upon exertion, cough, and dizzy spells. The client denies chest pain, loss of consciousness, and fever. Vital signs are stable with the exception of the oxygen saturation, which is 86% according to the pulse oximeter. For which of the following potential scenarios will the nurse monitor? Select all that apply.
A nurse enters the room and notices her client has a heart rate of 132 on the monitor. The nurse knows that which of the following is the priority nursing intervention?
A client has been brought into the emergency department after being involved in a car accident. The nurse applies a probe to the client’s finger to measure the oxygen saturation levels. Which factors would affect the ability to obtain a normal oxygen saturation reading? Select all that apply.
The nurse is attempting to count the heart rate on an EKG graph and notices the client has an irregular rhythm. The nurse knows that which of the following is the best method to obtain an accurate heart rate?
A client was found lying outside in the snow unconscious and brought to the emergency room. Upon assessment, the nurse finds that the client has a temperature of 92.1 F and the nurse is unable to palpate the left radial pulse. The nurse should do which of the following first?
The nurse is caring for a client with a heart rate of 150 bpm, a blood pressure of 70/44, respirations at 28 per minute, and an O2 saturation of 91%. Which of the following interventions should the nurse anticipate doing next??
A nurses receives report on several clients. The nurse knows to be most concerned about hyperthermia with which of the following client temperatures?
The nurse receives report on a client with active chest pain and a type B aortic dissection noted on CT. The client has an arterial line placed. Which is the most important vital sign to monitor?
A nurse is assessing a client in the primary care clinic and notes an elevated pulse rate. Which of the following factors would cause a person to have an increased heart rate? Select all that apply.
A client comes up to the medical unit from the ED with a temperature of 97.9s. Which of the following actions should the nurse take first?
