NR 324 Week 7 EDAPT_Altered Mobility

Self-Check: Nursing Assessment of Risk – Altered Mobility The nurse is caring for a client with a femur fracture. Currently the client is on bedrest with the effected leg elevated. Which prescription from the health care provider requires urgent action to prevent complications? Initiate fall precautions Sequential compression device Administer antibiotics as ordered Physical therapy referral Self-Check: Nursing Actions – Hematologic Alterations Nursing Actions – Altered Mobility Review the nursing actions below. Select the nursing diagnosis that best fits these actions. Self-Check: Outcome – Nursing Evaluation The nurse is caring for a patient who was involved in a motor vehicle accident. The client is alert and requesting pain medication for a pain level of 8 on a 1 to 10 scale. The client does not have elevated blood pressure or pulse and does not appear to be in distress. Non-pharmacological treatment has not worked. The client is due to receive the pain medication at this time as needed. Which of the following is most appropriate? Administer normal saline and tell the patient it is pain medicine Give the pain medicine as ordered Hold pain medicine Notify the healthcare provider of your concerns Self-Check: Analyze Cues – Altered Mobility The nurse is teaching a class and looks for some examples of different things that can affect treatment of altered mobility. Review the examples below and identify the barrier to each situation from the drop-down choices. Nursing Diagnoses – Planning Interventions Ernestine has a fractured hip. In developing the care plan, the nurse identifies some interventions that will help Ernestine. Match the nursing diagnosis with the most appropriate intervention. Planning Care – Fracture Review the nurse’s progress note below, and answer the following questions. Time Nurse’s Progress Note 14:00 Ernestine reports pain in her hip. Vitals: BP-152/88, P-102, R-24. Oxygen saturation 96%. She describes it as a soreness with intermittent throbbing. The nurse asks her to identify her pain as a 6 on a numeric pain scale. She received ketorolac 60mg IM at 10:00. Question 1 / 2 Based on the information available, select the appropriate nursing actions from the prescriptions below. Select all that apply. Acetaminophen 500mg PO q4-6 hours for mild pain Ketorolac 60mg IM q6 hours for moderate pain Play some of her favorite music Morphine 4mg q2 hours for severe pain Ice pack to the right hip Reposition Question 2 / 2 What is the expected outcome to measure with your interventions? Client will have a respiratory rate less than 24 Client will verbalize that she has no pain Client will have a 20 point reduction in systolic blood pressure Client will verbalize a reduction of pain on the numeric pain scale Client will have decreased pulse rate Client will ambulate 100 feet with minimal pain Recognizing and Analyzing Assessment Cues - Amputation The nurse is reviewing Martha’s post-operative prescriptions. Drag the correct nursing diagnosis to match the given prescription. Nursing Outcomes - Amputation Review the nursing discharge note and check if the goal is being met at