The nurse is preparing a preoperative plan of care for an older Hispanic patient who is scheduled for a hysterectomy. What does the nurse recognize as the priority initial intervention?
1. Teach the patient about turning, coughing, and deep breathing.
2. Discuss the patient's concerns about the surgery.
3. Explain that the patient's pain will be controlled during the postoperative time frame.
4. Determine if the patient understands English or if an interpreter is needed.
4
Rationale 1: Teaching about postoperative breathing exercises is not the first priority.
Rationale 2: Discussing patient concerns is important but is not the first priority.
Rationale 3: Pain control is important but is not the first priority.
Rationale 4: The initial intervention should be determining whether the patient speaks and understands English. If not, an interpreter must be provided so that the patient understands all preoperative instructions and education.
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Order: Vasopressin 3 milliunits/kg/hr Available: Vasopressin 20 units in 500 mL NS Client's weight: 55 kg The IV flow rate is _______________
a. 4 mL/hr b. 40 mL/hr c. 165 mL/hr d. 16 mL/hr
The health care provider has prescribed a client sodium warfarin (Coumadin) while he is still receiving intravenous heparin. Which is the nurse's best action?
a. Administer both heparin and warfarin as prescribed. b. Turn off the heparin before administering the warfarin. c. Clarify the warfarin order with the nursing supervisor. d. Hold the warfarin dose until the heparin is discontinued.
The nurse is preparing an IV setup for a pediatric client and decides to use a volumetric infusion pump. The decision is based on knowledge of these pumps and their ability to:
a. decrease nursing assessment and monitoring time b. maintain constant intravascular pressure within the IV access c. maintain the patency of the vascular access d. provide accurate flow rates
A nurse is caring for a client with terminal cancer at the client's home. Why should the nurse put greater emphasis on teaching with the family members taking care of the client?
A) Family members may have to manage the patient care controlled analgesia pump to manage the client's pain. B) Family members are expected to provide primary healthcare. C) Family members are required to understand the advanced technical levels of care. D) Hospital stays may need to be decreased.