A client who has just been transferred to the postanesthesia care unit (PACU) from surgery is very restless and confused. What is the nurse's first action?
a. Orient the client and remain with him or her.
b. Call the surgeon for an intraoperative re-port.
c. Notify the physician on call.
d. Assess the client's level of pain.
A
The client who is not oriented is at risk of falling. The nurse should remain with the client to en-sure safety, and should assign another staff member to the client if care has to be given to others. The client should not be left alone.
You might also like to view...
Constipation is defined as
A) the passage of fewer than three stools in any 7-day period. B) the passage of fewer than five stools in any 7-day period. C) the infrequent and painful expulsion of hard, dry stools. D) a subjective sensation of bowel fullness.
A child who is medically fragile is being discharged home after a long hospital stay. The child will require someone to provide medical treatments several times a day. In planning discharge, the nurse will:
1. Train all members of the family to take part in the child's care. 2. Plan for a home health nurse to visit the child four times a day to provide the medical treatment. 3. Determine with the family which family members may be trained to provide care for the child. 4. Evaluate the size of the child's room for therapy.
The nurse is presenting a class on the pathophysiology of the different abortions. Some of the causes are: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Chromosomal defects. 2. Insufficient or excessive hormonal levels. 3. Sexual intercourse in the first trimester. 4. Infections in the first trimester. 5. Cervical insufficiency.
A client with diabetes asks the nurse why regular eye examinations for glaucoma are needed. What is the nurse's most accurate response?
1. "Individuals with diabetes have a greater chance of developing glaucoma, and it is important to find this out early so that treatment can begin." 2. "An adverse effect of insulin is vision loss, and frequent examinations will catch problems at an early stage." 3. "The stress that you are under with this disease can result in an increased production of aqueous humor." 4. "Your diabetes is under such good control that it is probably not necessary to have eye examinations so frequently."