ttcyftxycf (329)-10

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University of Florida *

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4739

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Nursing

Date

Nov 24, 2024

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pdf

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Uploaded by ChiefOpossum3761

Rationale: When the other vital signs are within normal range, the immediate intervention would be to reassess the low oxygen saturation using another site before any other interventions are completed. Causes of low readings include client movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and fingernail polish. A nurse is caring for a client diagnosed with an acute anxiety disorder. Which of the following is the priority nursing intervention? Select one: a. Evaluate coping mechanisms for controlling anxiety. b. Administer prescribed selective serotonin inhibitor (SSRI). c. Encourage to attend a behavioral therapy group. d. Remain with the client during the crisis period. - ✔✔ d. Remain with the client during the crisis period. Rationale: This action is priority. It is imperative that the nurse remain with the client and provide safety and comfort measures during the crisis period of the anxiety disorder. This will increase the likelihood of anxiety relief and ensure client safety during the acute period. When the nurse takes morning medications to a client, the client states "I've never seen that one before." Which of the following is the most appropriate action for the nurse to take? Select one: a. Administer the rest of the medications and recheck the one that was questioned. b. Return to the nurse's station and check all medications against provider orders c. Recheck the medication with the medication administration record (MAR). d. Tell the client that the medication must be new and to go ahead and take it. - ✔✔ b. Return to the nurse's station and check all medications against provider orders

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