The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?
A) Assessing for hemorrhage
B) Maintaining a patent airway
C) Managing the patient's pain
D) Assessing vital signs every 30 minutes
Ans: B
Feedback:
The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital sign are also important, but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.
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An older male patient has disclosed to the nurse his recent inability to achieve an erection. How should the nurse respond to the patient's statement?
A) "It's not unusual for older men to have the problem occasionally, but we need to make sure that it's not the result of something we can change.". B) "This is a very normal part of the aging process. Are there other ways of achieving sexual fulfillment that you and your wife could try?" C) "It's a myth that older men have difficulty gaining and maintaining erections, so a thorough medical investigation is likely the best plan.". D) "This is often an unintended result of medications. Try withholding your medications for a few days and see if the problem resolves itself.".
How should an individual be supported through the change process?
1. Recognition of contributions to build self-confidence 2. Given only a small amount of information concerning the change so as not to overwhelm with information 3. Instruction on any new processes within 6 weeks of the change occurring 4. Referral to the employee-assistance program
A patient reports awakening at 1 am after only 2 hours of sleep and being unable to return to sleep for several hours. The patient is becoming increasingly anxious and requests a sleeping medication that will not cause a hangover
The nurse anticipates that which drug will be prescribed? a. Zolpidem b. Zaleplon c. Flurazepam d. Trazodone
A frail elderly client who has been a resident of a long-term care facility for 5 years has been admitted to the acute care setting. Which of the following symptoms would suggest to the nurse that a vitamin deficiency exists?
1. Frequent headaches behind the eyes 2. Confusion when awakened in the night 3. Muscle pain and weakness 4. Excessive thirst