The nurse, caring for a patient with obstructive shock because of a pulmonary embolism, would implement which of the following orders FIRST?
1. normal saline infusion at 150 cc/hr
2. oxygen at 35 percent via endotracheal tube
3. obtaining chest x-ray and PTT
4. heparin infusion at 1,500 units/hr
2
Rationale: Although all of the orders listed would be appropriate for the patient with a pulmonary embolism, the nurse must prioritize care using airway, breathing, and circulation as a focus. Oxygenation must take priority over interventions such as infusions of normal saline and heparin, which relate to circulation. The x-ray and lab order must come after the patient has been stabilized.
You might also like to view...
While assisting a patient with limited mobility to perform range-of-motion exercises, the nurse plans to assess the patient's adduction of the arm, which is the patient's ability to:
A) Move the limb toward the midline of the body. B) Bend the joint so that the angle of the joint diminishes. C) Turn the limb towards the center of the body. D) Rotate the forearm so that the palm of the hand is down.
One way to monitor quality is by:
a. benchmarks c. practice guidelines b. regulatory compliance d. dashboards
Drug half-life refers to:
a. drugs that are similar and produce similar effects on the body. b. drug detoxification. c. half the time it takes for the drug to be metabolized out of the system. d. the time that it takes for the drug to be effective.
A client states "Nurse X always seems as though she is hiding behind her uniform." The nurse hearing this would assess Nurse X as
A. not seeming genuine to the client. B. transmitting fear of clients. C. unfriendly and aloof. D. controlling.