Which of the following nursing interventions would be appropriate for a client who has had an endotracheal tube removed?
1. Evaluate arterial blood gas analysis 2 hours after extubation.
2. Encourage the client to limit movement for the first day after extubation.
3. Provide oral care immediately after extubation.
4. Instruct the client that hoarseness will be present for at least 3 months.
3
Interventions for a client who has been extubated include providing oral care immediately after extubation. Arterial blood gases should be analyzed within 30 to 60 minutes after extubation. The client should be encouraged to deep breathe, cough, and turn in bed frequently to mobilize secretions. Hoarseness should resolve within a few days and not in 3 months.
You might also like to view...
An older male adult is taking aripiprazole (Abilify) for agitation. Which patient assess-ment is the nurse's priority to prevent catastrophic effects of the medication?
a. Oral and facial dyskinesia b. Mask facies, shuffling gait c. Muscle spasms of the face d. Repetitive aimless walking
Directions: Prepare the following strength solutions. Describe your calculations
800 mL of 3/4 strength Sustacal via gastrostomy over 6 hours
A 71-year-old patient is manifesting signs and symptoms of gout. When assessing him for signs and symptoms of gout, the nurse should pay particular attention to
a. dietary intake of foods high in cholesterol. b. mobility in the hip and knee joints. c. edema or discoloration of the great toe. d. a history of trauma or occupational injury.
Which clinical manifestations of withdrawal would be seen in a client who abuses opioids?
A. Decreased response to increased drug dosages B. Muscle twitching and profuse perspiration C. Anorexia and weight loss D. Sedation