The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP)
When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops
a. oxygen saturation of 93%.
b. respirations of 20 breaths/minute.
c. green nasogastric tube drainage.
d. increased jugular venous distention.
ANS: D
Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20, O2 saturation of 93%, and green nasogastric tube drainage are within normal limits.
You might also like to view...
The Labor and Delivery nurse and a nurse new to the Labor and Delivery unit are admitting a laboring client. The client is making groaning guttural sounds during contractions, and answering questions with one-word answers
The Labor and Delivery nurse simultaneously is quickly setting up the instruments and sterile field for this delivery while asking the admission questions between contractions. The experienced Labor and Delivery nurse has not yet completed a pelvic exam. The nurse new to Labor and Delivery understands that this is an example of: 1. An expert nurse assessing advanced labor and imminent delivery in the client. 2. The correct order of steps when admitting laboring clients. 3. Inconsistencies in an individual nurse's approach to client care. 4. Advanced nurse practice.
When teaching a local community about ways to conserve energy, which of the following would the community health nurse suggest?
A) Set the thermostat in the house to 68 degrees during the summer B) Open the blinds for sunlight during summer afternoon hours C) Replace any worn or lost insulation in the home D) Remove caulking from any broken windows or doors
patient recovering from an open cholecystectomy 3 days prior has not passed any flatus since surgery. Which finding suggests to the nurse that the patient may be experiencing a life-threatening condition?
1. Anorexia 2. Falling blood pressure 3. Respiratory rate of 24 4. Hypoactive bowel sounds
Any sympathomimetic drug will cause:
A) ataxia. B) tachycardia. C) hallucinations. D) hypothermia.