A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?
a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check the oxygen saturation.
ANS: D
Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.
You might also like to view...
A patient comes in with a bad case of poison ivy. He has been scratching the red, swollen area on his arm because it itches. The arm has become increasingly swollen over the last 3 days. The nurse anticipates the doctor is most likely to order what drug?
a. Somatotropin b. A corticosteroid c. A mineralocorticoid d. Luteinizing hormone
The nurse realizes that according to Erikson's model, a client who is establishing a family and becoming productive in society is in the stage of:
a. industry vs. inferiority. b. initiative vs. guilt. c. generativity vs. stagnation. d. integrity vs. despair.
What specific area of ethics does HIPAA address?
a. Privacy b. Justice c. Coercion to participate in a research study d. Informed consent
The nurse explains that a fundamental basis for the nursing process is:
a. that basic needs must be met by the indi-vidual without assistance. b. that patients and families appreciate an efficient health care system that functions without their input. c. a focus on disease control. d. that all persons have worth and dignity.