Ms. Jackson is transferred to a stretcher and taken to the operating room. The nurse assists Jackson off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions jackson for surgery.Which nursing diagnosis has the highest priority at this time?
a. ineffective protection
b. ineffective tissue perfusion
c. risk for perioperative-positioning injury
d. risk for imbalanced body temperature
Answer: c. risk for perioperative-positioning injury
You might also like to view...
Which task could be safely delegated by the nurse to the unlicensed assistive personnel (UAP)?
1. Caring of the client with the newly placed cast 2. Explaining to the client how to respond to itching under the cast 3. Caring of the insertion site for Crutchfield tongs 4. Caring of the client with a stable cast
The surgical incision of a patient recovering from a partial colonectomy for colon cancer is red and the skin around the sutures is taut and shiny. Which of the following do these findings indicate to the nurse?
1. the sutures need to be removed 2. a local wound infection that might deteriorate into an enterocutaneous fistula 3. the patient needs to use more pillows when deep breathing and coughing to splint the incision 4. the wound is healing
A patient with second-degree burns is treated with silver sulfadiazine (Silvadene)
A nursing student asks the nurse about the differences between silver sulfadiazine and mafenide (Sulfamylon), because the two are similar products, and both contain sulfonamides. What does the nurse tell the student about silver sulfadiazine? a. It causes increased pain when the medication is applied. b. It has a broader spectrum of antimicrobial sensitivity. c. It has antibacterial effects related to release of free silver. d. It suppresses renal excretion of acid, causing acidosis.
The nurse stops on the way home to assist in the care of victims of a multi-motor vehicle crash site. The emergency response team uses a five level triage system. In which order should the nurse triage victims?
1. Victim walking with a limp 2. Victim bleeding from a gaping leg wound 3. Victim with a pulse of 20 and apneic periods 4. Victim sitting on the side of the road staring 5. Victim with shallow respirations and chest pain