The nurse is caring for a postoperative client and gathers the following data: temperature 36
2°C, pulse 104, respirations 8, oxygen saturation 92%, pain level of 2, dressing is clean and dry, breath sounds reveal fine rales in the bases bilaterally. What is the nurse's priority intervention? 1. Ask the client to deep-breathe and cough.
2. Administer narcotic analgesic for pain.
3. Notify the doctor of the client's need for increased fluids.
4. Administer oxygen.
1
Rationale: The client's respiratory rate is low, possibly secondary to narcotic analgesics. Asking the client to deep-breathe and cough will help to improve oxygenation and clear secretions from the airways. If, after coughing and deep-breathing, the client returns to the same level of sedation and respiratory depression, the nurse will inform the RN. There is no need to increase fluids or administer oxygen, as the elevated pulse rate is not uncommon after surgery, and is not significantly elevated to require treatment.
You might also like to view...
With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that:
a. Kidney function returns to normal a few days after birth. b. Diastasis recti abdominis is a common condition that alters the voiding reflex. c. Fluid loss through perspiration and increased urinary output accounts for a weight loss of over 2 kg during the puerperium. d. With adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.
The nurse is conducting an assessment for a newborn who presents with a heart rate of 140, a strong cry is noted, muscle tone is active, reflexes are vigorous, and color is pink with blue hands and feet
Which Apgar score is most appropriate for the newborn? 1) 6 2) 8 3) 9 4) 10
Working to effectively educate groups is an important community nursing skill. The compo-nents of the learning situation that need to be evaluated before designing a teaching program include:
1. Evaluation of teacher's behaviors 2. Instructional objectives 3. The interest of the instructor 4. The principles of teaching
The nurse is caring for a client undergoing stage 3 of the alcohol withdrawal process. The client complains of "bugs crawling all over my skin." This is a manifestation of what withdrawal symptom?
A) Delirium tremens B) Alcohol hallucinosis C) Blackouts D) Tweaking