A pt has had an anterior cervical diskectomy with fusion and has returned from the recovery room. What is the priority assessment?
a. assess for the gag reflex and ability to swallow own secretions
b. check for bleeding and drainage at incision site
c. monitor vital signs and check neurological status
d. assess for patency of airway and respiratory effort
Answer: d. assess for patency of airway and respiratory effort
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The nurse is identifying outcomes for care provided to a new mother whose infant continues to spit up after feedings. Which outcome would be the most appropriate?
A) The baby will have forceful episodes of vomitus only once a day. B) The baby will have less episodes of spitting up after sitting upright after a feeding. C) The baby will spit up a large amount of vomitus only after the last feeding of the day. D) The baby will have fewer episodes of spitting up when the type of formula is changed.
A client has severe adult (acute) respiratory distress syndrome (ARDS) and has not responded to several different treatments. An independent nursing action that might help the client would be to
a. administer antioxidants as ordered. b. place the client in a prone position. c. turn the client every 2 hours. d. use meticulous hand-washing before client care.
The nurse is assessing a female patient who has an abnormally high level of parathyroid hormone. Which assessment findings would be consistent with this diagnosis?
Select all that apply. 1. muscle atrophy 2. muscle weakness 3. diarrhea 4. weight gain 5. hypotension
A nurse who is working in the post-anesthesia care unit (PACU) recognizes that a patient is most likely to experience which of the following complications while in the unit?
1. Hypoventilation 2. Deep vein thrombosis 3. Atelectasis 4. Pneumonia