A patient, admitted with bloody diarrhea and coffee-ground emesis, was alert and oriented but is now demonstrating lethargy. Which of the following should the nurse be expected to do to assist this patient?
1. prepare for emergency intubation
2. transfer to a step-down unit
3. administer vasopressin
4. monitor vital signs every 6 hours
1
Rationale: Since the patient's level of consciousness is changing, the patient may need endotracheal intubation to protect the airway. The patient should be in an intensive care unit and not transferred to a step-down unit at this time. Vasoconstrictive medications are not appropriate at this time since hypovolemia is causing hypotension. The vital signs should be assessed more frequently than every 6 hours.
You might also like to view...
Mrs. Carson, 89 years old, takes the senior ride van to her daily swimming lesson, where she spends 45 minutes with four friends doing water aerobics
The only complaint anyone ever has is how difficult it is to hear the instructions because the instructor does not use a loudspeaker. This health-promotion activity is properly designed except a. It is not accessible b. It is not reasonable c. It is not sensitive to the needs of the older adult d. It is not enjoyable and social
The nurse is determining the amount of IV fluids to administer in a 24-hour period to a child who weighs 40 kg. How many milliliters should the nurse administer?
A) 1,000 mL B) 1,500 mL C) 1,750 mL D) 1,900 mL
During a routine physical examination, a preadolescent tells the nurse, "I am too fat and I'm going to do whatever I can to look like the girls on the cover of fashion magazines.". The nurse realizes that the client is exhibiting:
1. Unrealistic expectations. 2. Societal influences on body weight for girls. 3. Family influences on body weight. 4. A desire for a long-term profession.
Nurses in a small town that experienced the devastation of a number of tornados last year have formed a group to address the issue of disaster planning in their community
Which of the following are actions the nurses might take to prepare for another potential disaster? Select all that apply. a. Form a disaster plan for their own families b. Complete continuing education in disaster preparedness c. Encourage all residents of the town to move to a more urban area d. Become a volunteer for local or national disaster relief organizations e. Obtain information about rights and responsibilities in employment settings and understate law f. Do nothing because disasters such as tornados cannot be prevented