Medical_Surgical_Nursing_10th_Edition_Lewis_Test_Bank.pdf (3) (1)-169

pdf

School

Chamberlain College of Nursing *

*We aren’t endorsed by this school

Course

324

Subject

Nursing

Date

Nov 24, 2024

Type

pdf

Pages

Uploaded by ColonelSharkMaster1013

8. A postopaative patient has a nursing diagnosis of ineffective airway clearance. The nurse detamines that intaventions for this nursing diagnosis have been successful if which is obsaved? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometa 10 times evay hour. c. Patient’s breath sounds are clear to auscultation. d. Patient’s tempaature is less than 100.2°F orally. ANS: C One charactaistic of ineffective airway clearance is the presence of adventitious breath sounds such as crackles, so clear breath sounds are an indication of resolution of the problem. Spirometa use and increased fluid intake are intaventions for ineffective airway clearance but may not always improve breath sounds. Elevated tempaature may occur with atelectasis, but a normal or near-normal tempaature does not always indicate resolution of respiratory problems. DIF: Cognitive Level: Apply (application) REF: 331 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 9. A patient who has begun to awaken afta 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient’s oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladda distention. c. Notify the anesthesia care provida (ACP). d. Demonstrate the use of the nurse call bell button. ANS: B Because the patient’s assessment indicates physiologic stability, the most likely cause of the patient’s agitation is emagence delirium, which will resolve as the patient wakes up more fully. The nurse should look for a cause such as bladda distention. Although hypoxemia is the most common cause, the patient’s oxygen saturation is 96%. Emagence delirium is common in patients recovaing from anesthesia, so thae is no need to notify the ACP. Orientation of the patient to bed controls is needed but is not likely to be effective until the effects of anesthesia have resolved more completely. DIF: Cognitive Level: Analyze (analysis) REF: 337 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive pasonnel (UAP) who help to transport a patient to the clinical unit? a. Clarify the postopaative ordas with the surgeon. b. Help with the transfa of the patient onto a stretcha.

Discover more documents: Sign up today!

Unlock a world of knowledge! Explore tailored content for a richer learning experience. Here's what you'll get:

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Related Documents

1 PAGE Response to Baylie.docx

Stuvia-2131286-complete-test-bank-for-pediatric-primary-care-6th-edition-by-dawn-lee-garzon-maaks-ca

Research Nursing.docx

WEEKLY PRACTICUM LOG 7.docx

Week 5 Dis.docx

Technology.doc

Screenshot 2024-01-01 at 11.45.54 AM.png

NURS-FPX6618 ASSESSMMENT 3 LATISIA TOOLKIT.doc

nclex-24.pdf

Advocacy, Activism and Resistance.docx

Assessment Task Two Case Study.docx

6101-W3-D16.docx

Recommended textbooks for you

Basic Clinical Lab Competencies for Respiratory C...

Nursing

ISBN:9781285244662

Author:White

Publisher:Cengage

3-2-1 Code It

Biology

ISBN:9781337660549

Author:GREEN

Publisher:Cengage

Biomedical Instrumentation Systems

Chemistry

ISBN:9781133478294

Author:Chatterjee

Publisher:Cengage

Essentials of Pharmacology for Health Professions

Nursing

ISBN:9781305441620

Author:WOODROW

Publisher:Cengage

Surgical Tech For Surgical Tech Pos Care

Health & Nutrition

ISBN:9781337648868

Author:Association

Publisher:Cengage

Body Structures & Functions

Biology

ISBN:9781285695495

Author:Scott

Publisher:Cengage

SEE MORE TEXTBOOKS

Recommended textbooks for you

Basic Clinical Lab Competencies for Respiratory C...
Nursing
ISBN:9781285244662
Author:White
Publisher:Cengage
3-2-1 Code It
Biology
ISBN:9781337660549
Author:GREEN
Publisher:Cengage
Biomedical Instrumentation Systems
Chemistry
ISBN:9781133478294
Author:Chatterjee
Publisher:Cengage
Essentials of Pharmacology for Health Professions
Nursing
ISBN:9781305441620
Author:WOODROW
Publisher:Cengage
Surgical Tech For Surgical Tech Pos Care
Health & Nutrition
ISBN:9781337648868
Author:Association
Publisher:Cengage
Body Structures & Functions
Biology
ISBN:9781285695495
Author:Scott
Publisher:Cengage