An older adult who is on bed rest has tachycardia and dry mucous membranes after surgery. Which of the following is the nurse's priority for preventive care because of the patient's fluid volume status?
a. Bowel obstruction c. Thromboembolic events
b. Delirious behavior d. Delayed wound healing
C
This older adult is at high risk for a thromboembolic event as a result of bed rest and dehydration. Because it is a potentially life-threatening situation, the nurse's priority is to prevent a throm-boembolic event, including deep venous thrombosis and pulmonary embolism. The patient is likely to have low circulating blood volume as evidenced by tachycardia, which is a compensa-tory mechanism when the tissues receive inadequate oxygenation. In addition, compensatory mechanisms that help restore fluid balance are limited in the older adult. This limitation results in poorer tissue perfusion and an increased risk for thrombus formation for a patient who is on bed rest; a lack of skeletal muscle action promotes pooling of blood in the extremities.
Dehydration can lead to constipation and, in extreme cases, a bowel obstruction; however, this potential gastrointestinal issue is not the nurse's priority because circulation issues take pre-cedence. Dehydration increases the risk of delirium, especially in a patient who is hospitalized, but dehydration has a lower priority than the circulation issue. Dehydration increases the risk of delayed wound healing; optimal wound healing occurs in a moist environment. However, de-layed wound healing is a secondary concern until the nurse manages the circulation issue.
You might also like to view...
A college-aged student has influenza. At what stage of the infection is the student most infectious?
A) Incubation period B) Prodromal stage C) Full stage of illness D) Convalescent period
The nurse recognizes that values clarification interventions are beneficial for the client when:
1. The client and nurse have different beliefs 2. The client is experiencing a values conflict 3. The nurse is unsure of a client's personal values 4. The client has chosen to reject the normal values
You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change?
A. Sodium 136 mEq/L, potassium 4.5 mEq/L B. Sodium 145 mEq/L, potassium 4.8 mEq/L C. Sodium 135 mEq/L, potassium 3.6 mEq/L D. Sodium 144 mEq/L, potassium 3.7 mEq/L
A nursing instructor is describing the use of a head-to-toe approach for a comprehensive health assessment and how body systems may be combined, using the legs as an example
Which of the following would the instructor describe as being included in this assessment? Select all that apply. A) Skin color and condition B) Cardiovascular system C) Peripheral vascular system D) Neurologic system E) Musculoskeletal system