Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed?
a. Risk for skin breakdown
b. Impaired gas exchange
c. Ineffective airway clearance
d. Risk for infection
C
Patients with tracheotomies rely on the tracheostomy to provide a stable open airway. The nurse is most concerned about a dementia patient who is extubating himself unknowingly. The nurse is also concerned that the patient would not be able to cough up his own secretions and could occlude the tracheostomy, putting him at risk for Ineffective airway clearance. Nursing priorities are airway, breathing, and circulation. Frequently occurring nursing diagnoses should be addressed before "Risk" diagnoses. Skin breakdown and infection are not immediately life threatening.
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A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the:
a. Affected extremity will eventually regain its function. b. Pain is felt at one site but originates from another location. c. Patient's pain will be associated with nausea, pallor, and diaphoresis. d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain.
Which of the following would the nurse include in the plan of care for a dying child with pain?
A) Administering analgesics as needed B) Using measures the nurse finds comforting C) Playing the television or radio so the child can hear it D) Changing the child's position frequently but gently
A male patient with hepatitis C will begin triple drug therapy with pegylated interferon alfa 2a [Pegasys], ribavirin [Ribasphere], and boceprevir [Victrelis]. The patient tells the nurse that his wife is pregnant. What will the nurse tell him?
a. Boceprevir is contraindicated in males whose partners are pregnant. b. He should use a barrier contraceptive when having sex. c. He should use dual drug therapy with pe-gylated interferon alfa and ribavirin only. d. This combination drug therapy is safe for him to use.
A patient has mixed venous oxygen saturation (SVO2) of 52% with the following hemodynamic findings: CO of 4.8 L/min, SaO2 of 95%, and an unchanged hemoglobin level. The nurse should assess the patient for:
1. Excessive sedation 2. Position of the PA catheter 3. Hypothermia 4. Pain