The patient with a normal pregnancy had an emergency cesarean birth under general anesthesia 2 hours ago. The patient now has a respiratory rate of 30, pale blue nailbeds, a pulse rate of 110, and a temperature of 102
6°F, and is complaining of chest pain. The nurse understands that the patient most likely is experiencing: 1. Pulmonary embolus.
2. Pneumococcal pneumonia.
3. Pneumonitis.
4. Gastroesophageal reflux disease.
3
Rationale 1: Pulmonary embolus does not cause fever.
Rationale 2: General anesthesia does not cause pneumococcal pneumonia.
Rationale 3: Pneumonitis that results from aspiration of gastric secretions during general anesthesia is also referred to as Mendelson syndrome. Women with emergency cesareans are at greatest risk for this complication.
Rationale 4: Gastroesophageal reflux disease does not cause a fever or cyanosis.
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The nurse notes a positive shifting dullness. Which diagnosis does this assessment finding support?
1) Ascites 2) Liver enlargement 3) Pancreatitis 4) An abdominal mass
To provide patient care of the highest quality, nurses utilize an evidence-based practice approach because evidence-based practice is
a. A guide for nurses in making clinical decisions. b. Based on the latest textbook information. c. Easily attained at the bedside. d. Always right for all situations.
If a resident complains of abdominal pain, the nursing assistant should
a. assure the resident that it is most likely gas pains. b. report the pain immediately to the supervisor. c. ignore the patient. d. offer to give the resident an enema
Which assessment would you complete first?
a. Assessing ability to move the extremities b. Determining pupil response to light c. Auscultating breath sounds d. Testing the peripheral reflexes