Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is
A) hypokalemia or hyponatremia.
B) acute gastrointestinal bleed.
C) increased intracranial pressure.
D) respiratory depression.
D
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The nurse will gather information about which organ system to figure a patient's Sequential Organ Failure Assessment (SOFA) score?
1. Integumentary 2. Lymphatic 3. Hematologic 4. Endocrine
The patient is coughing up white mucus after having been intubated for surgery. What action would be most appropriate for the nurse to maintain a patent airway?
a. Administer supplemental oxygen. b. Place the patient in a supine position. c. Perform oropharyngeal suctioning. d. Prepare for endotracheal intubation.
An older client has been receiving cimetidine (Tagamet). The nurse should report to the physician that the client is experiencing a side effect of the medication if which of the following is noted during the assessment?
1. Tremors 2. Stiff joints 3. Confusion 4. Constipation
What should the nurse do when caring for a client who is receiving peritoneal dialysis?
a. maintain the client in the supine position during the procedure b. position the client from side to side if fluid isn't draining adequately c. remove the cannula at the end of the procedure and apply a dry, sterile dressing d. notify the health care provider if there is a deficit of 200mL in the drainage return