Answer to Question 1
3. The client with pneumonia may be experiencing respiratory distress.
Rationale:
The client with a PaCO2 of 85 could be in serious trouble. The nurse would decide to assess that client first in order to prevent dire consequences for the client. The client with pneumonia probably needs more care than the other client, but the reason for the decision is based on a potentially critical need by the client with pneumonia. The nurse cannot delegate discharge teaching to a UAP; even if delegation were permitted, the nurse would see the client with a high PaCO2 as being the greater priority. Placement of the client's room can be a decision that is made when considering time management issues; however, the physiological needs of the clients are the first consideration of the nurse.
Answer to Question 2
2. I am not hearing the voices anymore..
Rationale:
Among the therapeutic effects of clozapine (Clozaril) is the remission of a range of psychotic symptoms that include delusions, paranoia, auditory hallucinations, and irrational behavior. A client stating he feels better and is ready for discharge does not indicate the remission of any psychotic symptoms. A client stating he will go to group therapy does not indicate the remission of any psychotic symptoms. A client stating he will not skip breakfast does not indicate the remission of any psychotic symptoms.
The nurse cares for the postop client in the postanesthesia care unit (PACU).
A client is having an endoscopy performed by a physician who views the upper gastrointestinal intern
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