The patient is being admitted to the intensive care department ...

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The patient is being admitted to the intensive care department with multiple fractures and internal bleeding. Which of the following are considered roles of the nurse in this situation? (Select all that apply.)
 
  a. Anticipate physical and social deficits to resuming normal activities
  b. Involve the family and significant others in the plan of care
  c. Assist in making health care resources available to the patient
  d. Identify the psychological needs of the patient

Question 2

The patient is brought to the emergency department complaining of severe shortness of breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient's respiratory status, the nurse should:
 
  a. remove the patient's nail polish to get a pulse oximetry reading.
  b. use a forehead probe to get a pulse oximetry reading.
  c. use a finger probe to get a pulse oximetry reading.
  d. check the color of the patient's nail polish before attempting a reading.

[smrerig]

Answer to Question 1

A, B, C, D
The nurse identifies patients' ongoing health care needs; anticipates physical, psychological, and social deficits that have implications for resuming normal activities; involves family and significant others in a plan of care; provides health education; and assists in making health care resources available to the patient. To separate the processes of admission and discharge is a critical error; the two are simultaneous and continuous.

Answer to Question 2

B
Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO2 (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish Cieck et al., 2010; medications such as bronchodilators).