The nurse admits a patient to the surgical unit from the postanesthesia care unit. The patient has an oral airway in place and awakens only to painful stimuli. What is the priority nursing action?
a. Remove the oral airway and elevate the head of the bed.
b. Position the patient with the head turned to the side.
c. Measure vital signs and check surgical dressing.
d. Call the surgeon and obtain postoperative prescriptions.
B
The oral airway should not be removed until the patient is more awake, and elevating the head of the bed is not appropriate until the patient is more responsive. The most important priority is to position the patient with the head turned to the side to prevent aspiration of secretions or emesis if the patient should vomit. Vital signs and dressing checks are important but not the highest priority. Postsurgical prescriptions are written when the patient is in postanesthesia care and come to the floor with the patient.
You might also like to view...
The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?
a. Dilation of the pupils b. Consensual light reflex c. Conjugate movement of the eyes d. Convergence of the axes of the eyes
A 51-year-old man is being discharged from the hospital following treatment with anticoagulants for a deep vein thrombosis. The nurse will instruct the patient to
A) alternate between the types of anticoagulant drugs in the therapy. B) consider safety measures to prevent bleeding and be alert for signs of bleeding. C) change the route of administration to intravenous if oral proves ineffective. D) eat small amounts of food during drug administration.
A nurse is admitting a new patient through the emergency room after collapsing at home. The patient's girlfriend states that he has been really sick the last few days and complained of feeling dizzy just before losing consciousness
The nurse takes the following vital signs: temperature of 38.7°C, pulse of 121 beats per minute, blood pressure of 87/52, and respiratory rate of 32 breaths per minute. The nurse observes that he is diaphoretic. After running a CBC, the white blood cell count is 14,532. After stabilizing him, the nurse calls the ICU to prepare them to treat which of the following? A. Shock B. Sepsis C. DIC D. Heart failure
Find the flow rate in gtt/min: ________.Ordered: 1,800 mL RL q24h using tubing calibrated to 10 gtt/mL
Fill in the blank(s) with the appropriate word(s).