One hour after admission to the postanesthesia care unit (PACU), the postoperative client has become very restless. What is the nurse's first action?
a. Assess for bladder distention.
b. Assess the oxygen saturation level.
c. Call the surgeon to assess the client.
d. Administer pain medication as ordered.
B
The most common causes of restlessness in the immediate postoperative period are hypoxemia and pain. Although pain control is very important, determining the adequacy of ventilation in this case has higher priority.
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Ms. Ron is the Patient Care Manager of the mobile intensive care unit (MICU). She wants to make a change in the culture of the unit so that more experienced nurses take on the less expe-rienced nurses as mentees and not just preceptees
An effective first step for Ms. Ron to carry out with the staff before making this change is to: A. Conduct a Readiness to Change Assess-ment to identify how the staff feels on this issue. B. Announce that being a mentor is now part of the job description of any MICU nurse that has more than 5 years' experience. C. Meet with all of the experienced nurses and tell them the unit cannot survive without each one of them being responsi-ble for a less experienced nurse. D. Discuss with the Staffing Supervisor if there are any extra MICU nurses that can be scheduled so only experienced nurses who volunteer will have to be mentors.
The nurse suspects that a patient is experiencing a response to stress. By which route should the nurse expect hormone transport to be conducted in this stress response?
A. Portal B. Nerve cell extension C. Neuroendocrine D. Paracrine
When caring for a patient with emphysema, the nurse would include which of the following diagnoses as priority in the plan of care?
A) Ineffective coping B) Self-care deficit C) Activity intolerance D) Impaired gas exchange
A nurse engaged in active listening is paying close attention to
a. verbal communication only. b. all sensory data resulting from the patient's messages. c. selecting an appropriate listening response. d. preparing responses to the patient's comments.