When the postsurgical patient complains of shortness of breath, the nurse should immediately:
1. raise the head of the bed to 30 degrees.
2. take vital signs.
3. perform a focused assessment.
4. inform the charge nurse.
1
Although all these options will be eventually performed, the initial implementation should be to raise the head of the bed to ease breathing, perform a focused assessment with vital signs and O2 concentration, and then inform the charge nurse about the patient's symptoms and your assessment findings.
You might also like to view...
A client experiencing tetraplegia is in the emergency department. The nurse has started an IV line, and anticipates administering:
1. pain medication. 2. a high dose of Solu-Medrol. 3. antibiotics. 4. anti-anxiety agents.
The nurse monitors an infant diagnosed with Nezelof's syndrome for which commonly associated condition?
A) Infections B) Thrombocytopenia C) Thymus gland failure D) Tinnitus
Which statement is true about patient classification systems?
a. The systems measure all the needs of patients. b. The systems provide an absolute formula for unit staffing. c. The systems should not be used to make patient care assignments because acuity systems are more accurate. d. The systems provide historical data of the usage of nursing time, which is helpful when developing the department budget.
For those individuals who no longer require invasive monitoring but are not yet ready for a general medical or surgical ward, care would be delivered in a:
a. high-dependency unit (HDU). b. intensive care unit (ICU). c. special care unit (SCU). d. none of the above.