The nurse is assessing an unconscious patient for placement of an oropharyngeal airway. In addition to a present gag reflex, what other conditions would make the use of the airway con-traindicated? (Select all that apply.)
a. A semi-conscious patient
b. A patient with a loose tooth
c. A patient who had facial trauma
d. A patient who has had oral surgery
e. A patient with copious secretions
A, B, D
An oropharyngeal airway should never be inserted in a patient with recent oral trauma, oral sur-gery, or loose teeth. A semi-conscious pateint may vomit or have spasms of the larynx if an air-way is inserted. Patients at greater risk for upper airway obstruction are adults with loss of con-sciousness, seizure disorders, neuromuscular diseases, increased oral secretions or excretions, or facial trauma.
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The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse?
a. Bounding b. Normal c. Weak d. Absent
A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; PERRLA is intact
His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed and 40 ml of urine is present. What is the nurse's most likely explanation for the urine output? A) The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place. B) The man has a brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin. C) The man is in heart failure and is releasing atrial natriuretic peptide that results in decreased urine output. D) He is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.
The nurse evaluates a patient's risk for developing a pressure ulcer using the Norton scale. The patient's score is 18. The nurse should:
1. call the physician immediately. 2. implement a pressure ulcer prevention program. 3. document the score. 4. order an alternating air mattress.
Experience-oriented therapy engages the client in which of the following activities?
a. ways-of-being within the therapy session b. discovery of unconscious knowledge c. homework experiences d. conscious thought changes