Answer to Question 1
A
A patient who has a recent myocardial infarction can convert back to a deadly rhythm and needs to be placed on continuous cardiac monitoring. The patient has COPD and should not be placed on oxygen over 4 L/min. Proper cardiac functioning will allow oxygenated blood to be distributed to tissues. Patients with recent myocardial infarction should not be suctioned. This patient does not have any indicators to warrant hourly assessment of lung fields.
Answer to Question 2
A
Stating the observation of the client having a Bible opens communication regarding the client's source of strength. Assessing a client's sources of strength and faith can direct interaction with him or her, including medical treatment plans.
What do you believe happens to your spirit when you die? is not the best response, as it does not provide information that would assist the nurse in meeting the client's spiritual needs.
We would allow members of your church to visit you whenever you desire is not the best re-sponse, as it implies that the client goes to church or should go to church, and assumes that church members are a source of strength for the client. It does not provide assessment infor-mation to determine the client's spiritual needs.
Has your terminal condition made you lose your faith or beliefs? is not the best response. It has a negative connotation and does not assess the client's sources of strength or the beliefs of the client.
All messages must be documented and placed in the patient's chart.
Inspecting a patient’s ear during a physical examination.
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