The emergency department nurse admits a patient following a motor vehicle collision
Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? a. Insertion of an 18-gauge peripheral intravenous line
b. Application of cushioned heel protectors
c. Implementation of fall precautions
d. Implementation of universal precautions
A
Given the patient's diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume is a priority and can be accomplished following insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration. Universal precautions, fall precautions, and application of heel protectors are appropriate interventions but are not the immediate priority.
You might also like to view...
An older male adult with severe knee pain tells the nurse how he lost his job and his home after starting a new business when he was 48 years old. Now he lives alone and relies on Social Security
Using Jung's theory, what in this individual's life is the most pivotal in his personality development? a. Living alone b. Meager income c. Severe knee pain d. Job and home loss
Which patient would be a candidate for thrombolytic therapy?
1. A patient with acute pericarditis 2. A patient with a dissecting aortic aneurysm 3. A patient with massive pulmonary emboli 4. A patient with a cerebral neoplasm
Disposable razors may be discarded in the wastebasket.
Answer the following statement true (T) or false (F)
What is the mechanism of action of drugs used to treat thromboembolic disease?
a. Dissolving clots and preventing formation of new clots b. Making platelets more flexible and preventing formation of new clots c. Causing vasodilation and increased blood flow d. Preventing platelet aggregation and inhibiting clot formation