The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first?
a. Take the blood pressure.
b. Assess patient orientation.
c. Check the oxygen saturation.
d. Observe for facial asymmetry.
ANS: C
The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange.
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A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound. The nurse anticipates providing which care for this patient's wound?
1. Irrigating the wound twice daily before applying dry dressing 2. Caring for a split thickness skin graft 3. Applying wet-to-dry dressings 4. Caring for a suture line created by surgical closure of the wound
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