The nurse, when collecting data on a patient 48 hours after surgery for a fractured femoral shaft, notes mental confusion, tachycardia and tachypnea, dyspnea, high blood pressure, and petechiae on the chest and reports the findings to the RN
What nursing interventions are appropriate while awaiting the physician's specific orders? (Select all that apply.)
a. Place patient in high Fowler's position or raise the head of the bed.
b. Ask patient to move affected limb to see if pain is worse.
c. Prepare patient for chest x-ray or lung scan.
d. Maintain bedrest and keep movement to a minimum.
e. Administer oxygen.
f. Prepare patient for arterial blood gas tests.
ANS: A, C, D, E, F
A, C, D, E, F. A fat emboli is likely. The patient is placed in high Fowler's position to aid breathing, diagnostic tests will be done, and the patient is kept on bedrest to reduce oxygenation needs and clot movement. Oxygen may be started per agency policy to aid in respiration. B. Limb should not be moved to prevent further release of fat.
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The nurse is educating the patient about alternative therapies. Which statement by the patient indicates a need for more information?
a. Alternative therapies can include relaxation techniques. b. Alternative therapies are used in conjunction with medical therapies. c. Alternative therapies can be used when patients are experiencing stress. d. Some alternative therapists require certification.
A 44-year-old female patient presents to the emergency department with abnormal bleeding and abdominal pain that is later attributed to gallbladder disease
Which of the following diagnoses would the medical team be most justified in suspecting as a cause of the patient's bleeding?
A) Excess calcium
B) Vitamin K deficiency
C) Hemophilia B
D) Idiopathic immune thrombocytopenic purpura (ITP)
The nurse is caring for a client with a pelvic fracture. Which is the nurse's priority action to prevent complications?
a. Monitor temperature daily. b. Insert a urethral catheter. c. Monitor blood pressure frequently. d. Turn the client every 2 hours.
Two nurses on a psychiatric unit come from different backgrounds and have graduated from different universities. They are given a set of new orders from the unit manager. Each nurse displays different emotions in response to the orders
Nurse A indicates that the new orders include too many changes; Nurse B disagrees and verbally indicates why. This step in the process is which of the following in Thomas' Stages of Conflict? a. Frustration b. Conceptualization c. Action d. Outcomes