Palpable radial pulse
Palpable ulnar pulse
Capillary refill within 3 seconds
Bluish fingernails, cool and pale fingers
Objective data from a secondary source
Objective data from a primary source
Subjective data from a primary source
Subjective data from a secondary source
Chronic Renal Failure
In an adult, pull the pinna upward.
Instill the medication directly into the tympanic membrane.
Warm the medication at room or body temperature.
Press the tragus of the ear a few times to assist flow of medication into the ear canal.
Tell her not to cry and it will be better.
Provide opportunity to the client to tell their story.
Encourage her to accept or to replace the lost person.
Discourage the client in expressing her emotions.
None of the above
2nd CN (Optic)
3rd CN (Occulomotor)
4th CN (Trochlear)
7th CN (Facial)
Absence of family support
Decreased sensory functions
Patient has no interest on learning
Decreased plasma drug levels
It is useful on outpatient settings.
It progresses in separate, unrelated steps.
It focuses on the patient, not the nurse.
It provides the solution to all patient health problems.
Weight loss of 3 lbs in a 120 lb female patient.
Diminished breath sounds in patient with previously normal breath sounds
Patient stated, “I feel less nauseated.”
Change of heart rate from 70 to 83 beats per minute.
Regularity of meal times
3-day diet recall
Eating style and habits
Place the client on the left side of the bed.
Attach the feeding bag to the current tubing.
Elevate the head of the bed.
Cold the formula before administering it.
Shallow breaths interrupted by apnea.
Prolonged gasping inspiration followed by a very short, usually inefficient expiration.
Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea.
Increased rate and depth of respiration.
Temperature of 38 0C
Vomiting for 3 days
Patient stated, “My arms still hurt.”