The nurse is caring for a patient who requires emergency surgery for injuries sustained in a motor vehicle accident. The patient was on his way back to work after having lunch with colleagues when the accident happened. What is the highest priority nursin
a. Risk for imbalanced body temperature
b. Risk for aspiration
c. Risk for perioperative positioning injury
d. Risk for delayed surgical recovery
ANS: B
Risk for aspiration is the highest priority because the patient has not been NPO and his stomach is filled with food after lunching with his colleagues. The patient may easily aspirate stomach contents into the airway when general anesthesia is administered, so precautions must be taken to prevent this from happening. The other nursing diagnoses certainly apply but are not as important as risk for aspiration.
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