7 hours ago Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with esophageal varices who has a rapid heart rate b. A patient with a history of gastrointestinal bleeding who has melena c. A patient with nausea who has a dose of metoclopramide (Reglan) due d. A patient who is crying after receiving a diagnosis of esophageal cancer >> Go To The Portal
The response beginning, "It is important that you be realistic" discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis. Which information will the nurse provide for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a.
The nurse should avoid doing painful procedures close to mealtimes, but nausea or vomiting that occurs at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition.
d. "I sleep with the head of the bed elevated on 4-inch blocks." ANS: B GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD. A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli.
Assist the patient to the commode every 2 hours during the day A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure?
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to
b. Reposition the patient every 1 to 2 hours.
The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning is needed
Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range
a. The patient's oxygen saturation is 93%.
Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient
ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?
A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)?
a. Insert an oral airway during the seizure to maintain a patent airway.