The nurse has completed a teaching session for a client with a ...

[EAugust]

The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include which of the following?
 
  1. Language
   2. Supplies required
   3. Client's questions
   4. Need for additional teaching

Question 2

A client receiving heparin therapy for deep venous thrombosis complains of severe chest pain and shortness of breath. The nurse suspects pulmonary embolism and should do which of the following actions first?
 
  1. Increase the rate of heparin infusion
   2. Apply oxygen and elevate the head of the bed
   3. Reassure the client and notify family members
   4. Assess pulse, respirations, and blood pressure

[juliaf]

Answer to Question 1

4. Need for additional teaching

Rationale:
The parts of the teaching process that should be documented in the client's chart include the need for additional teaching. Documenting the client's language is not necessary as it should already be in the nursing history. Supplies required for teaching are not documented. Client's questions are not documented, but the client's understanding at the end of the session is documented.

Answer to Question 2

2. Apply oxygen and elevate the head of the bed

Rationale:
Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate of heparin infusion will not provide any information on the client's activated partial thromboplastin time (aPTT) level, nor would it provide any information on the physician's order regarding regulating the infusion according to the aPTT level. Reassuring the client and notifying family members are not the priority, although these measures are designed to decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of the bed to increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure will be performed following the initiation of oxygen therapy and bed elevation.