2.7 Learning Activities
Learning Activities
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)
- The nurse is conducting an assessment on a 70-year-old male client who was admitted with atrial fibrillation. The client has a history of hypertension and Stage 2 chronic kidney disease. The nurse begins the head-to-toe assessment and notes the patient is having difficulty breathing and is complaining about chest discomfort. The client states, “It feels as if my heart is going to pound out of my chest and I feel dizzy.” The nurse begins the head-to-toe assessment and documents the findings. Client assessment findings are presented in the table below. Select the assessment findings requiring immediate follow-up by the nurse.
Vital Signs
| Temperature | 98.9 °F (37.2°C) |
|---|---|
| Heart Rate | 182 beats/min |
| Respirations | 36 breaths/min |
| Blood Pressure | 152/90 mm Hg |
| Oxygen Saturation | 88% on room air |
| Capillary Refill Time | >3 |
| Pain | 9/10 chest discomfort |
| Physical Assessment Findings | |
|---|---|
| Glasgow Coma Scale Score | 14 |
| Level of Consciousness | Alert |
| Heart Sounds | Irregularly regular |
| Lung Sounds | Clear bilaterally anterior/posterior |
| Pulses-Radial | Rapid/bounding |
| Pulses-Pedal | Weak |
| Bowel Sounds | Present and active x 4 |
| Edema | Trace bilateral lower extremities |
| Skin | Cool, clammy |
2. The following nursing actions may or may not be required at this time based on the assessment findings. Indicate whether the actions are “Indicated” (i.e., appropriate or necessary), “Contraindicated” (i.e., could be harmful), or “Nonessential” (i.e., makes no difference or are not necessary).
| Nursing Action | Indicated | Contraindicated | Nonessential |
|---|---|---|---|
| Apply oxygen at 2 liters per nasal cannula. | |||
| Call imaging for a STAT lung CT. | |||
| Perform the National Institutes of Health (NIH) Stroke Scale Neurologic Exam. | |||
| Obtain a comprehensive metabolic panel (CMP). | |||
| Obtain a STAT EKG. | |||
| Raise the head-of-bed to less than 10 degrees. | |||
| Establish patent IV access. | |||
| Administer potassium 20 mEq IV push STAT. |
3. The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among Critical needs, Urgent needs, Routine needs, and Extras.
You are the nurse caring for the patients in the following table. For each patient, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.
| Critical | Urgent | Routine | Extra | |
|---|---|---|---|---|
| Patient exhibits new left-sided facial droop | ||||
| Patient reports 9/10 acute pain and requests PRN pain medication | ||||
| Patient with BP 120/80 and regular heart rate of 68 has scheduled dose of oral amlodipine | ||||
| Patient with insomnia requests a back rub before bedtime | ||||
| Patient has a scheduled dressing change for a pressure ulcer on their coccyx |
||||
| Patient is exhibiting new shortness of breath and altered mental status | ||||
| Patient with fall risk precautions ringing call light for assistance to the restroom for a bowel movement |
