You have been floated to the surgical unit and are caring for a patient who has had a spinal fusion. The patient is receiving IV pain medication. You hear the patient calling out loudly about the "snakes crawling all over the bed
" You consider several reasons for the patient's behavior, including drug reaction, electrolyte imbalance, and infection. In this case, your first priority is to:
A) Call the doctor immediately
B) Report to the charge nurse immediately
C) Reassure the patient that there are no snakes and offer him or her a back rub
D) Stop the IV medication
A
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A nurse is caring for a patient in the active phase of labor. The woman's BOW spontaneously ruptures. Suddenly the woman complains of dyspnea and appears restless and cyanotic. Ad-ditionally, she becomes hypotensive and tachycardic
The nurse immediately suspects the presence of ____________________. Fill in the blank(s) with correct word
A patient has a lactate level of 8 mmol/L. The nurse realizes that this finding indicates:
1. Carbon dioxide exchange 2. Underuse of oxygen 3. Glucose metabolism 4. Tissue hypoxia
A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints
1. Pad bony prominences on the wrist. 2. Apply the padded portion of the restraint around the wrist. 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.
When an adult is not breathing but has a heartbeat, you would provide rescue breathing. How often should you give a breath?
A. Every minute B. Every five seconds C. Every twenty seconds D. Every two minutes