The nurse admits the client to the PACU after hand surgery; the client is awake after receiving conscious sedation and regional anesthesia. Which intervention is the nurse's priority?
1. Maintain a patent airway.
2. Elevate the affected hand.
3. Monitor circulatory status.
4. Measure body temperature.
1
1. Although the client did not receive general anesthesia, the nurse's priority is maintaining the airway because short-acting benzodiazepines and opioids used during conscious sedation potentially depress respirations. If the client is very lethargic, the client can have trouble maintaining the airway and require temporary support.
2, 3, and 4. After establishing a stable airway, breathing, and circulation, the nurse elevates the hand according to the provider's preference and takes the client's temperature to establish baseline data.
You might also like to view...
Which of the following would be most appropriate to assess first for the newly admitted Chinese patient?
a. Pain b. Language barrier c. Family support d. Religious preference
A nurse is preparing a patient who will stop taking lorazepam [Ativan] for anxiety and begin taking buspirone [Buspar]. Which statement by the patient indicates a need for further teaching?
a. "I can drink alcohol when taking Buspar, but not grapefruit juice." b. "I may need to use a sedative medication if I experience insomnia." c. "I may not feel the effects of Buspar for a few weeks." d. "I should stop taking the Ativan when I start taking the Buspar."
A pregnant woman's mother is worried that her daughter is not "big enough" at 20 weeks. The nurse palpates and measures the fundal height at 20 cm, which is even with the woman's umbilicus
What should the nurse report to the woman and her mother? a. "The body of the uterus is at the belly button level, just where it should be at this time." b. "You're right. We'll inform the practitioner immediately." c. "When you come for next month's appointment, we'll check you again to make sure that the baby is growing." d. "Lightening has occurred, so the fundal height is lower than expected."
The nurse realizes that the medication tiotropium bromide (Spiriva) is contraindicated for a patient with chronic obstructive pulmonary disease (COPD). What information in the patient's medical history led to this clinical decision?
Select all that apply. 1. The patient is being treated for glaucoma. 2. The patient uses a topical steroid for psoriasis. 3. The patient attends physical therapy three times a week. 4. The patient is taking medication for prostatic hypertrophy. 5. The patient limits the intake of dietary fats for weight loss.