The nurse establishes the nursing diagnosis Ineffective airway clearance for the client in the postanesthesia care unit. Which does the nurse implement to maintain a patent airway?
1. Administer supplemental oxygen.
2. Place the client in supine position.
3. Perform oropharyngeal suctioning.
4. Prepare for endotracheal intubation.
3
3. In the immediate postoperative period, clients frequently have pulmonary secretions from mechanical ventilation during surgery; the nurse suctions the client as necessary to help remove the secretions from the airway.
1. Supplemental oxygen is ineffective therapy to clear an airway.
2. The supine position is contraindicated for clients in the immediate postoperative period unless the client is hypotensive.
4. The nurse avoids preparing for endotracheal intubation unless the client desaturates and develops respiratory failure.
You might also like to view...
When educating a patient about glargine (Lantus), the nurse should explain that this medication
A) has a rapid onset and peaks in about 5 minutes after injection, so he will need to eat food immediately after injection. B) will have a peak effect within 30 minutes, so it can be taken after a meal. C) is a combination with short-acting and intermediate-acting insulin, so it is safe to take anytime throughout the day. D) has a prolonged absorption rate and provides a relatively constant concentration for 12 to 24 hours.
A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse are advisable?
1) Reassure the patient by entering the room alone. 2) Ask the patient if he is carrying any weapons. 3) Stay between the patient and the door; keep the door open. 4) Make eye contact while stating firmly "I will not tolerate cursing and threats."
A patient tells the nurse that the only thing that helps him sleep is a glass of warm milk
The nurse caring for the patient insists that this practice is a myth and tries to convince the patient that reading a book will help to make him sleepy. What is the nurse demonstrating? A) Cultural pervasiveness B) Cultural superiority C) Stereotyping D) Ethnocentrism
Which of the following would healthcare providers most likely identify as the primary concern associated with e-mails between patients and healthcare providers?
A) Lack of time to become involved B) Lack of interest in electronic communication C) Inadequate staff to handle the communication D) Privacy of the communication