2.7 Learning Activities

1. 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 client 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

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).

3. The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing client 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 clients in the following table. For each client, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.