Author Question: When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is ... (Read 103 times)

krzymel · **on:** Jul 22, 2018

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by

a. Ambulating in the hallway two times this shift.
b. Turning side to back to side with assistance every 2 hours.
c. Using the walker correctly to ambulate to the bathroom as needed.
d. Using a sliding board correctly to transfer to the bedside commode as needed.

Question 2

The nurse is caring for a patient who has a temperature reading of 100.4 F (38 C). His last two temperature readings were 98.6 F (37 C) and 96.8 F (36 C). The nurse should

a. Call the physician and anticipate an order to treat the fever.
b. Assume that the patient has an infection and order blood cultures.
c. Wait an hour and recheck the patient's temperature.
d. Be aware that temperatures this high are harmful and affect patient safety.

elizabethrperez · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
The patient is ordered to be on bed rest; therefore turning the patient in bed is the only option that is appropriate. When determining goals, the nurse needs to ensure that the goal is individualized and realistic for the patient.

Answer to Question 2

C
Waiting an hour and rechecking the patient's temperature would be the most appropriate action in this case. A fever usually is not harmful if it stays below 102.2 F (39 C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Mild temperature elevations enhance the body's immune system by stimulating white blood cell production. Usually, staff nurses do not order blood cultures, and nurses should base actions on knowledge, not on assumptions.