The nurse is planning care for a patient who experienced a near-drowning. What should the nurse identify as the goal of care for this patient?
a. Maintain ventilation
b. Decompress the stomach
c. Drain fluid from the lungs
d. Drain fluid from the stomach
ANS: A
If a person survives submersion, acute respiratory failure may follow. The incidence of serious pulmonary complications is high in this group, so ensuring the patient's respiratory status is the priority. B. C. D. The goals of care for this patient may or may not include stomach decompression, removing fluid from the lungs, or draining fluid from the stomach.
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The patient is 68 years old. This person would be classified as
a. middle-aged c. old old b. young old d. oldest old
While in the postanesthesia care unit, a patient recovering from spinal surgery tells the nurse that she cannot feel her right hand and that her right shoulder is painful. The nurse realizes the patient is exhibiting signs of:
1. Brachial plexus nerve injury. 2. Infiltrated intravenous access site. 3. Thromboembolism in the brachial artery. 4. Residual effects of spinal anesthesia.
You are the RN giving discharge instructions to your client who has metastatic lung cancer and mucositis. You know the client understands the instructions when she says:
1. "I will use half-strength normal saline rinses at least three times per day until my mouth sores heal.". 2. "I will swab my mouth with mouthwash every 4 hours to reduce the sores.". 3. "I will refrain from brushing and flossing my teeth until the sores heal.". 4. "I will rinse my mouth with full-strength peroxide every hour until the sores heal.".
Which of the following is an unsafe condition?
A) loose steps B) wet floors C) dimly lit hallway D) all of the above