The nurse is caring for a postoperative patient following a laryngectomy. The patient has been a heavy smoker for 25 years. The nurse observes that the patient is coughing copious thin white sputum. The nurse should:
A) Suction the patient.
B) Contact the patient's physician immediately.
C) Apply oxygen non-recreate mask at 10 L.
D) Assess the patient for bleeding.
Ans: A
Feedback: The nurse should suction the patient and have the patient cough and deep breathe. If these measures are not successful, the nurse should contact the patient's physician immediately because this may be life threatening.
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A patient is to receive a medication every twelve hours. The first dose was administered at 2100h. At what time will the next dose be administered (expressed as standard time)? ____ a.m. on the next day. Standard Text:
Fill in the blank(s) with correct word
The nurse evaluates the lab reports for the patients on the unit, and recognizes the report requiring the most immediate attention is for the patient with RBCs, _____ mil/mm3; WBCs, _____ mil/mm3; and Hb, _____ g/dL
a. 4.2; 4500; 9.1 b. 5.9; 4500; 12.7 c. 6.0; 6000; 13.2 d. 7.6; 8000; 18.0
An infant at 36 weeks' gestation was just delivered; included in the protocol for a preterm infant is an initial blood glucose assessment. The nurse obtains the blood and the reading is 58 mg/dL. What is the priority nursing action based on this reading?
a. Document the finding in the newborn's chart. b. Double-wrap the newborn under a warming unit. c. Feed the newborn a 10% dextrose solution. d. Notify the neonatal intensive care unit (NICU) of the pending admission.
The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which of the following interventions are appropriate? (Select all that apply.)
A. Place a small pillow between bony surfaces. B. Elevate the head of the bed to 45 degrees. C. Limit fluids and proteins in the diet. D. Use a lift sheet to assist with repositioning. E. Reposition the client who is up in the chair every 2 hours. F. Keep the heels off the bed surfaces.G. Use a rubber ring to decrease sacral pressure when up in the chair.