What is particularly important for the nurse to assess in a patient who is beginning noninvasive ventilatory support? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Patient orientation and level of alertness
2. Respiratory pattern, depth
3. Status of skin of the nose
4. Bowel sounds and presence of insufflation
5. Peripheral pulses
1,2,3,4
Rationale 1: The nurse needs to ensure that the patient remains alert enough to manage the airway and remove the mask if emesis occurs.
Rationale 2: It is important for the nurse to monitor respiratory pattern, depth, and effort.
Rationale 3: Pressure ulcers on the bridge of the nose are common and care should be taken to assess the skin.
Rationale 4: Forcing air into the oropharynx makes gastric insufflation a potential complication of noninvasive ventilation. The nurse needs to monitor the patient for gastric distention.
Rationale 5: The nurse does not need to assess peripheral pulses because the patient is on noninvasive ventilation.
You might also like to view...
A patient has been diagnosed with partial seizures. What behaviors during this patient's seizures that would not occur during a generalized seizure does the nurse expect?
A) Aura prior to seizure B) Twitching confined to one arm C) Absence of purposeful movement D) Postictal period or state
The nurse attempting to develop a plan of care that addresses a client's spirituality should incorporate measures to address
a. broad concepts related to values, meaning, and purpose. b. only those individual aspects of the self that the client has shared with the nurse. c. the client's religion and the specific degree of participation in the church. d. the personal relationship between God and the client.
What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will:
a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.
Identify the type of impulse that sensory nerves carry to the brain.
A. Touch B. Pain C. Heat and cold D. All of the above