A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min.
Which of the following abbreviations should the nurse use?
(Select all that apply.).
O2.
NC.
LPM.
SpO2.
RR.
Correct Answer : A,B,D,E
The nurse should use the following abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min:.
• O2: This stands for oxygen and indicates the type of gas being delivered to the patient.
• NC: This stands for nasal cannula and indicates the device used to deliver oxygen to the patient.
• SpO2: This stands for peripheral oxygen saturation and indicates the percentage of hemoglobin that is saturated with oxygen in the blood.
It is measured by a pulse oximeter attached to the patient’s finger or earlobe.
• RR: This stands for respiratory rate and indicates the number of breaths per minute that the patient takes.
It is an important vital sign to monitor in patients with respiratory conditions.
Choice C is wrong because LPM is not an accepted abbreviation for oxygen therapy. LPM stands for liters per minute and indicates the flow rate of oxygen being delivered to the patient. However, it should not be abbreviated as LPM, but written out in full or as L/min. This is to avoid confusion with other abbreviations such as lpm (lowercase L) which stands for light per minute, a unit of luminous flux.
Normal ranges for SpO2 and RR vary depending on the age, health status and activity level of the patient, but generally they are:.
• SpO2: 95% to 100% for healthy adults.
Lower values may indicate hypoxemia (low blood oxygen level) or other conditions affecting oxygen delivery or uptake in the body.
• RR: 12 to 20 breaths per minute for healthy adults.
Higher or lower values may indicate respiratory distress, infection, pain, anxiety or other conditions affecting breathing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“The client in room 14 has a wound dressing that needs to be changed at 10 a.m.”
This statement is appropriate for handoff communication because it provides relevant and specific information about the patient’s care plan and any pending tasks that need to be completed by the next nurse.
It also allows for the opportunity for discussion and clarification between the nurses.
Choice A is wrong because it is subjective and disrespectful to the patient.
It does not convey any useful information about the patient’s condition, needs, or preferences.
It may also create a negative bias or impression on the next nurse, which could affect the quality of care.
Choice C is wrong because it is not timely or relevant for handoff communication.
The patient’s allergies should be documented in the electronic health record (EHR) and verified with the patient before administering any medications.
It is not necessary to repeat this information during every handoff, unless there is a change or concern.
Choice D is wrong because it is too vague and incomplete for handoff communication.
It does not provide any details about the patient’s current status, vital signs, medications, interventions, or goals.
It also does not indicate any anticipated changes or potential complications that the next nurse should be aware of.
Handoff communication is a critical element of patient safety and continuity of care.
It involves the transfer of essential patient data from one caregiver to another during transitions of care across the continuum.It should be interactive, accurate, concise, and standardized.Some examples of handoff communication tools are SBAR (Situation, Background, Assessment, Recommendations), I PASS the BATON (Introduction, Patient, Assessment, Situation, Safety concerns, Background, Actions, Timing, Ownership, Next), ISHAPED (Introduction, Story, History, Assessment, Plan, Error prevention, Dialogue), and kardex.
These tools help to structure and organize the information exchange between providers and ensure that nothing is missed or misunderstood.
References:.
:12 patient handoff communication tools to know - Becker’s ASC.
:Handoff communication - standardizing nursing protocols.
:Communication Strategies for Patient Handoffs | ACOG.
:8 Tips for High-quality Hand-offs - The Joint Commission.
Correct Answer is C
Explanation
Assess the client’s understanding and readiness for discharge.
This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.
The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.
Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.
The nurse should not threaten or coerce the client to stay in the hospital against his will.
Choice B is wrong because it is not the priority at this time.
The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.
Choice D is wrong because it is not the first action that the nurse should take.
The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.
A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels.It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.
Some of the benefits of cardiac catheterization are:.
• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.
• It can help determine the best treatment plan for the client based on his or her specific condition and needs.
• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.
• It can reduce the need for more invasive surgery or repeated hospitalizations.
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