13.2: Chapter 2
- Page ID
- 63233
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Answer Key to Chapter 2 Learning Activities
1.
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* |
Lungs 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.
Nursing Action | Indicated | Contraindicated | Nonessential |
---|---|---|---|
Apply oxygen at 2 liters per nasal cannula. | X | ||
Call imagining for a STAT lung CT. | X | ||
Perform the National Institutes of Health (NIH) Stroke Scale Neurologic Exam. | X | ||
Obtain a comprehensive metabolic panel (CMP). | X | ||
Obtain a STAT EKG. | X | ||
Raise head-of-bed to less than 10 degrees. | X | ||
Establish patent IV access. | X | ||
Administer potassium 20 mEq IV push STAT. | X |
Answers to interactive elements are given within the interactive element.