The nurse is taking care preoperatively of a client who will be having a coronary artery bypass graft (CABG). What is a priority nursing intervention for this client?
1. Ensure the client and family understands the various tubes that the client will have when the family first sees the client.
2. Teach the client to request pain medication when the pain is unbearable.
3. Discuss the location of the bed controls in the intensive care unit.
4. Teach the client about an incentive spirometer.
Ensure the client and family understands the various tubes that the client will have when the family first sees the client.
Rationale: The client and family need to understand the location of the incision and the various tubes that the client will have in place when the family first sees the client. Pain management is of concern to a CABG client, but is often managed initially by the nurses since the client is heavily sedated. The location of the bed controls in the ICU becomes an issue after the client arrives there. The use of an incentive spirometer occurs after the client is extubated.
You might also like to view...
On the way to surgery, a patient expresses doubt about proceeding with the planned procedure. The patient states that the doctor did not explain it very well and she would like to talk to her again before starting the procedure
The nurse knows the surgery schedule is very tight, reassures the patient that everything will be all right, and administers the preoperative sedation. This scenario describes what possible type of negligence? a. Assessment failure c. Implementation failure b. Planning failure d. Evaluation failure
Which patient would the nurse prioritize as needing emergency treatment, assuming no other injuries are present except the ones outlined below?
A) A patient with blunt chest trauma with some difficulty breathing B) A patient with a sore neck that was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with acute confusion due to a drug reaction
The nurse is preparing to document care provided to a client. The major reason for accurate and thorough documentation of nursing care rendered and the client's response to interventions is because documentation:
a. is required for accreditation and reimbursement. b. prevents lawsuits. c. is required if a client sues. d. is a long-held custom.
A risk factor for the development of delirium in older adults is:
A) Age-related cognitive changes that make older adult clients more susceptible to changes in mental status. B) A lack of rigorous exercise that leads to decreased cerebral blood flow. C) Administration of multiple medications that may cause drug-drug interactions or toxicity. D) Decreased social interaction that leads to profound isolation and psychosis.