A nurse should plan to implement which action as part of the routine morning care for a hospitalized patient who has just returned from having ECT (electroconvulsive therapy) therapy?
a. Have a walker available for use if the patient is unsteady on their feet.
b. Measure and record all vital signs, including orientation, once per shift.
c. Check the gag reflex before administering medications and offering breakfast.
d. Wake the patient up every 30 minutes to assess and document neurological status.
C
The nurse should check the gag reflex before offering medications and breakfast so that the patient does not aspirate because of the effects of general anesthesia. The nurse should use side rails and assist the patient to walk if unsteadiness is present. Vital signs should be measured every 15 minutes initially and then less often, but once per shift is insufficient after this procedure. Neurological status should be assessed every 30 minutes while the patient is awake, but the patient should not be awakened. It is thought that sleep helps return the patient to baseline more quickly.
You might also like to view...
What would be the greatest difference in care delivery when comparing the hospital-based nurse to the community and public health nurse?
1. The hospital-based nurse does not have to follow as many policies as the community and public health nurses. 2. The community and public health nurses have a higher degree of autonomy and independence than the hospital-based nurse. 3. All three groups of nurses perform their jobs identically. 4. The community and public health nurses do not have to document care as much as the hospital-based nurse.
A nurse is educating students on the history of quality improvement. The teaching has been effective when one of the students states that the historically, quality improvement focused on
a. "controlling process by inspection so that errors were prevented.". b. "quality improvement did not begin until recently.". c. "proactive approaches to lessen errors.". d. "error prevention strategies.".
A nurse is caring for a Sunni Muslim patient. The nurse demonstrates cultural sensitivity by
a. allowing the patient to pray three times daily. b. placing the patient's dinner tray on top of the Koran. c. offering the patient food and fluids during Ramadan. d. positioning the patient's bed in a southeast direction from the United States.
Which of the following topics most closely conforms to the priorities that have been suggested for future nursing research?
A) Attitudes of nursing students toward smoking B) Nursing staff morale and turnover C) Effectiveness of nurse-managed centers D) Number of doctorate-prepared nurses in various clinical specialties