You receive C.P. from the recovery room. How will you focus your initial assessment, and why?
What will be an ideal response?
• Your assessment should begin with the ABCs.
Airway: Assess for hoarseness and weak voice because of edema or damage to the recurrent laryngeal
nerve; ask C.P. to immediately report any sensation of swelling or tightening in her airway.
Breathing: Assess for any signs of respiratory distress, such as stridor, and ask C.P. to immediately
report any choking sensation or difficulty breathing or swallowing.
Circulation: Assess patency and adequacy of the IV access to accommodate rapid IV infusion or
the irritant calcium gluconate as needed. Assess for hemorrhage into the neck tissues; check the
surgical site and dressing; note swelling or ecchymosis; monitor VS.
• Check for tetany (calcium deficiency secondary to parathyroid tissue removal).
• Check to see whether the ice bag needs to be refilled.
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A 32-year-old female patient is taking tizanidine (Zanaflex) for spasticity related to her multiple sclerosis. The nurse will inform the patient and her husband that the adverse effect that poses the greatest safety risk to the patient is
A) constipation. B) dry mouth. C) fatigue. D) hypotension.
Which of the following findings should a nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?
A) Serum thyroid level findings B) Arterial blood gas (ABG) findings C) Red blood cells (RBCs) and hemoglobin count findings D) White blood cell count findings
The client who is about to be discharged asks the nurse for suggestions on how to improve the quality of her sleep so that she can wake feeling refreshed in the morning. The nurse reviews the client's history and suggests: (Select all that apply
) 1. Adjust the temperature in the room to a comfortable level. 2. Change the time of aerobic exercise to one hour prior to sleep. 3. A cup of tea before bed is relaxing. 4. Limit the use of alcohol to early in the evening. 5. Do not smoke before bedtime.
The nurse observes unlicensed assistive personnel (UAP) taking the following actions when caring for a female patient with a urethral catheter. Which action requires that the nurse intervene?
a. Taping the catheter to the skin on the patient's upper inner thigh b. Cleaning around the patient's urinary meatus with soap and water c. Disconnecting the catheter from the drainage tube to obtain a specimen d. Using an alcohol-based gel hand cleaner before performing catheter care