Nursing management of the patient with acute lung failure includes which of the following interventions? (Select all that apply.)
a. Positioning the patient with the least affected side up
b. Providing adequate rest between treatments
c. Performing percussion and postural drainage every 4 hours
d. Controlling fever
e. Pharmaceutical medications to control anxiety
A, B, D, E
The goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Patients with diffuse lung disease may benefit from being positioned with the right lung down because it is larger and more vascular than the left lung. For patients with alveolar hypoventilation, the goal of positioning is to facilitate ventilation. These patients benefit from nonrecumbent positions such as sitting or a semierect position. In addition, semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia. Frequent repositioning (at least every 2 hours) is beneficial in optimizing the patient's ventilatory pattern and ventilation/perfusion matching. These include performing procedures only as needed, hyperoxygenating the patient before suctioning, providing adequate rest and recovery time between various procedures, and minimizing oxygen consumption. Interventions to minimize oxygen consumption include limiting the patient's physical activity, administering sedation to control anxiety, and providing measures to control fever.
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The first priority for the nurse is to: 1. Offer to contact outpatient services if the client promises that she will not return home after her discharge. 2. Encourage the client to take charge of her situation. 3. Make it clear to the client that her husband needs to see a therapist. 4. Assist the client to devise a safety or escape plan.
The nurse assesses that smoking, drinking alcohol, and exercising compulsively, which may occur as responses to a stressful situation, are which of the following types of responses?
1. External 2. Withdrawal 3. Denial 4. Internal
Delayed capillary refill may alert you to:
a. hypovolemic shock. b. moderate hypoxemia. c. subnormal intracranial pressure. d. upper respiratory infection.
Which of these patient scenarios is most indicative of critical thinking?
a. Administering pain relief medication according to what was given last shift b. Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past c. Offering pain relief medication based on physician orders d. Explaining to the patient that his reports of severe pain are not consistent with the minor procedure that was performed