The nurse assesses a client for surgery. Which information does the nurse report to the surgeon before surgery?
1. Client complains of a pounding headache.
2. Client has a bruise on the left anterior chest.
3. Vital signs include an oxygen saturation at 88%.
4. Blood pressure is 20 mm Hg higher than baseline.
3
3. The nurse reports the oxygen saturation because the value should be greater than 95%. A value as low as 88% indicates a PaO2 less than 80 mm Hg; before the client can go to surgery, the PaO2 needs to be at least 80 to 100 mm Hg. The solution can include supplemental oxygen, increasing the oxygen carrying capacity of the blood, or coughing and deep breathing.
1, 2, and 4. A headache, a single bruise, and a mild elevation in the blood pressure usually will not contraindicate surgery. The headache and blood pressure potentially result from anxiety or hypoglycemia and are common with preoperative clients.
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Which of the following patient histories is most likely for a person older than 65 years of age?
A) In the last year, Patient F has been treated for a skin rash, a sprained ankle, and influenza B) Patient G takes medications daily for arthritis pain relief and reduction of blood pressure levels C) Patient H complains of chronic fatigue, stress-related allergies, and acid reflux after meals D) Patient I has been to the emergency room three times in the past year for ear infections and allergy attacks
A patient underwent a retinal detachment repair. The nurse receives the following order from the patient's physician: Keep patient in upright sitting position, with head over the bed table, until first dressing change
What should the nurse do? A) Call the physician and tell him the order is an error and must be reviewed. B) Follow the order because this position will help keep the retinal repair intact. C) Instruct the patient to do this while awake but sleep lying flat on the unoperated side. D) Assume she should change the dressing at bedtime, then allow the patient to lie flat.
Prior to surgery, the nurse instructed the patient on exercises that should be done prior to and after surgery. The patient is currently recovering from surgery and is experiencing a deep vein thrombosis
Which preoperative exercise instruction was not adequate for this patient? 1. Leg exercises 2. Deep breathing and coughing 3. Use of incentive spirometry 4. Splinting when coughing
The nurse administers eardrops in the patient's left ear. Which of the following positions is appropriate after instillation of the drops?
a. Prone b. Upright c. Right lateral d. Dorsal recumbent with hyperextension of the neck