The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube
Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised? A) Obtain vital signs.
B) Monitor heart rhythm.
C) Auscultate lung sounds.
D) Assess capillary refill.
C
Feedback:
Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data.
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A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?
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A psychiatric nurse is caring for a client who is severely depressed. To promote self-esteem, which unit responsibilities could a nurse assign to this client?
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