During the immediate postoperative period following cardiac surgery, a patient is mechanically ventilated. Which of the following symptoms may indicate impaired gas exchange?
A) Bradycardia
B) Edema
C) Restlessness
D) Warm, moist skin
Ans: C
Feedback: Impaired gas exchange can produce symptoms of restlessness, anxiety, tachycardia, altered arterial blood gases, fighting the ventilator, and cyanosis of the tissues.
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An older patient dying of end-stage pulmonary disease and dementia receives narcotic medication for chronic pain. Currently the patient is restless and grimacing. How should the nurse interpret these assessment findings?
1. The patient is in pain. 2. The patient has an undiagnosed personality disorder. 3. The patient needs nonpharmacological pain management approaches. 4. The patient is not experiencing any difference in pain level and no adjustments are needed.
Which should the nurse attribute to the older adult's decreased skin elasticity? Select all that apply.
A. Elastin fibers decreases. B. Collagen decreases. C. Subcutaneous layer decreases. D. Sebum production decreases. E. Epidermis thins.
A nurse is assisting a client with his bed bath. The client states, "I can do it myself." The nurse's best response is:
A) I really have limited time. Let me give you your bath right now? B) I will set up your bath for you. I will come back and help you with your bath? C) You will need to sit up for your bath, and then I will change your bed? D) You will be able to take your bath by yourself tomorrow when you can get up?
A patient who has lung cancer calls the clinic reports facial and neck swelling severe enough so that shirts no longer fit. What question by the healthcare professional there would be most appropriate?
a. “Have you gained weight recently?” b. “Are your feet and ankles swollen?” c. “Does your voice sound hoarse?” d. “When was your last chemotherapy?”