A patient is admitted to the hospital after sustaining severe electrical burn. A tracheostomy is performed, and the patient is unable to use either hand.
... [Show More] It is MOST important for the nurse to take which of the following actions?
1. Obtain a closed-circuit video monitor
2. Pad the side rails of the bed
3. Obtain and blow-touch call bell
4. Transfer the patient with a Hoyer lift - Answer: Obtain a blow touch call bell.
The patient is unable to use either hand, so the most appropriate way for him to summon the nurse is with a blow-touch call bell.
The nurse expects which of the following modes of mechanical ventilation to be ordered for a patient with severe Guillain-Barre syndrome?
1. Controlled ventilation (CV)
2. Assist-control ventilation (AC)
3. Synchronized intermittent mandatory
ventilation (SIMV)
4. Continuous positive airway pressure
(CPAP) - Answer: Controlled ventilation (CV)
Patients with Guillain-Barre syndrome have flaccidity or weakness that progresses upward from the lower extremities and often includes the trunk, with resultant respiratory compromise and possible failure; motor deficits can progress to total quadriplegia; controlled ventilation is used for patients who are unable to initiate a breath, such as patients with polio or Guillian-Barre; it delivers a set tidal volume of oxygen at a set rate; this is the simplest mode, but is used less frequently than others.
Immediately following thoracentesis, the nurse notices a progressive swelling on the right side of the patient's chest and neck. The nurse knows which of the following conditions is the MOST likely cause of the swelling?
1. Pneumothroax post-thoracentesis
2. Subcutaneous emphysema
3. Lipoma
4. Hematoma formation - Answer: Subcutaneous emphysema
Subuctaneous emphysema is a complication of thoracentesis in which air leaks into subcutaneous tissue and cuases swelling; as more air enters the tissue, the swelling progresses. Crepitus is felt as a crackling sensation beneath the fingertips.
A patient is scheduled for rhinoplasty. Postoperatively, it is MOST important for the nurse to place the patient in which of the following positions?
1. Supine
2. Left Sims
3. Modifed Trenedelenburg's
4. Semi-Fowlers - Answer: Semi-Fowlers
The patient should be placed in a semi-Fowler's position to decreased edema, promote drainage, and facilitate breathing.
An adult is eating lunch and suddenly starts to choke, gasp for breath, and grab the throat. Which of the following actions should the nurse take?
1. Instruct the patient lean forward and administer back blows.
2. Offer the patient water to drink
3. Ask the patient to speak
4. Finger sweep the patient's mouth. - Answer: Ask the patient to speak [Show Less]